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UNIFIED PROGRAM CONSOLIDATED FORM I UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form ver UST) TYPE OF ACTION (Check one item only. ForUST permanent closure m 1emoVel,complete only this section and Sections I,II,III,IV,and IX below) 430 [31.NEW PERMIT ❑ 3.RENEWAL PERMIT IN 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE L j 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: °J0i DATE EXISTING UST DISCOVERED: u0b I FACELITY;INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAMDBA•D E or oing Business As) 3 PI't„. BUSINE S EAD KESS �[ 37 1039 AL S crrY � 1`6 9S-2.4 T 109 II.TAPTI(DESCRIPTION TANK m# 432 TANK MANUF 433 TANK CONFIGURATION:TIES TANK IS 434 ,4'� 1 /A//✓3 �2 { I.ASTAND-ALONE TANK l/� `l"" I ❑ 2.ONE IN A COMPARTMENTED UNUr. Co left one efm ah in Ne wut DATE UST SYSTEM INSTALLED 435 TANK ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 006 TMT USE:AND CONTENTS TANK USE I$-la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 C33.CHEMICALPRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE(1 Iw.uw OTO ❑ 5.EMERGENCY GENERATOR FUEL DISC¢2528L5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM; I$Is.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.3ET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): Mos NON-PETROLEUM:❑ 7.USED OI. --ff 10.ETHANOL ❑ It.OTHER NON-PFUROLEUM S i 490b PJ TANKgN3TRUCTION TYPE OFTANK ❑ I.SINGLEWALL SQ 2.DOUBLE WALL 095.UNKNOWN M3 PRIMARY CONTAINMENT ❑ 1.STEEL JR 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qM ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S 4Ma SECONDARY CONTAINMENT ❑ L STEEL (�3.FIBFIRGIASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.IACKECED 445 ❑ 90.NONE M 95.UNKNOWN ❑99.OTHERS ): MSs OVERFILL PREVENTION 1.AUDIBLE B VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V "PROV,il WASTE PIPING EONSTRUC:TION .... .. . .. PIPING CONSTRUCTION I.SMGLE-WALLED 2.DOUBLE-WALLED 4 99.OTHER 60 SYSTEM TYPE I.PRESSURE ❑2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION UCCR41636(a)(3) 458 PRIMARY CONTAINMENT Ll I.STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Speeify): 4Me SECONDARY CONTAINMENT E3LSTEEL 4.FIBERGLASS L3 &FLEXIBLE ❑ 10.RIGID PLASTIC 46/b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(specify): qMc PIPINGmmiNB CONTAINMENT SUMP TY PE I.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 46M VI:'F'ENT,VAPOR'RECOVER] (YRj ANiTRLSFR!'FII L PIPE PIPING CO]?iSTItUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTNER(Spmify) 4640 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) 4601 VR PRIMARY CONTAINMENT C1 L STEEL 4.FIBERGLASS 10.RIGID PLASTIC46411 ❑ 90.NONE U 99.OTHER(Specify) 4691 VR SECONDARY CONTAINMENT U 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTFIBR(Specify) 4464b VENT EM-TRANSMONSUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 469h1 4648 RISER PRIMARY CONTAINMENT 1,STEEL 4.FIBERGLASS U I0.RIGID PLASTIC U 90,NONE U 99.00HER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS LA 10.RIGID PSTIC 90.NONE 99.OTHER(Specify) 469k 4Mkl FILL COMPONENTS METALLED I.SPILL BUCKET .STRIKHUPLATEIBOTIOMPROTECTOR 191,4.CONTAINMENT SUMP 451. VII.UNDER'DISPEN `CONTAiNMENT(I)DC) CONSTRUCTION TYPE !SINGLE WALL ❑2.000BLE WALL ❑ 3.NO DISPENSERS El 90.NONE 469+ CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ou ) 19 VIII..,CORROSION:PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4,IMPRESSED CURRENT ❑ 6.ISOLATION M8. M APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the iuformadon pwv dedrhereiu Is true,accurate, and In full complince with legal requirements. APPLICANT SIGNATURE A PATE /� 1 0.9 _ 470. APPLICANT NAME(prinQ � q-n�f 071 1 APPLICANT TITLE �I® - 4M UPCF UST•B-1/2 Rev.(12/2007)