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APR-26-2012 (� 7P• 4 ,ZZ 53 Qui 2(, UNIFIED PROGRAM CONS IIA D FdRM I UNDERGROUND STORAGE TANK Q /z� OPER NG PERMIT APPLICATION-TANK INFORMATION(ona Tv m uST E OF ON ( jl hack oge-i oNy. Foran UST permnnwr closure w removal,complete only fills section and I. .� 3.RENEWAL PERMIT Sections I.II.III,IV,and IX below) 4E0 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE I 5.CHANGE OF INFORMATION DATE[IST PERMANFNTI.Y CLOSED: DM 8.UST REMOVAL DATE EXISTING UST DISCOVERED' � I. FACILITY INAE; ID p(Agency Ura Only) BUjr AMEI(Sa mFACILI N EorD A•Doing eminess As) 1 V s wtr �fll /D 3 BUSINEp$$I'SE D RE ' �'LJV 107 n la TANK IDsII.TANK Df 43a !� 7 TANK MANUFACTURER -Fl 454 8 ur,kk�„K DATE ST SYRTEM INSTALLED 4a7 TANK CAP! LL r - a0 � AN THE UNIT 4" TANK USE ❑ ia.MOTOR III.TANK E A VEMCLE FUELING ❑ Ib.MARINA FUELIT _ Q 7.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(m,,Wa u MAVIAUONPUELING 119 CONTENTS fi•OTHER GENERATOR FUEL LI veer wp 95.UNKNOWN Q 5.EMERUWCYGEN T R . L ,) PETROLEUM; 13la.REOULAR UNLEADED 99.OTHER • • C g LL( 43% ❑ 3,DIESEL ❑ Ic.MLDORADE UNLEADED Q 1 b.PReM1UM UNLEADED ❑ 8.PETROLEUM BLEND FUEL 5.JET FUEL AVIATION OAS O Ie&,F, 4a9 NON•PErROLEUM: 7.USED OIL 9,OTHER PETROLEUM S �f eµTleh I I.OTHER NON•PEfROLEUM9 Q 10.ETHANOL age IV. TANK CONSTRUCTION 40bTYPE OF TANK 1.SINGLE WAIL ❑ 2.DOUBLE WALL PRIMARY CONTAINMENT1.$TEEL11 95.UNKNOWN T,STEEL t INTERNAL LINING FIBERGLASS 6.INTERNAL HLADDRR 443 ARY 1.STEEL SECONbCONTAINMENT 95.UNKNOWN 99,pTHgg 3.PIBERGLAS9 6.EXTERIOR MEMS r V y11i 90•NONE ❑ 97.UNKNOWN LINER 7.7ACKETED 4d OVERFILL PREVENTION L 99.OTHER(9 mi I.AUD18LE @VISUAL ALARMS 2.BALI FLOAT aatn ❑ 4.TANK MEETS RE 3,FILL TUBE SHUTOFF VALVE NTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <sa. V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSINGLE•wALLED SYSTEM TYPE ❑2.DOUBLE.WALLED 99,OTHER PRfMARY CONTAINMENT 1.STEEL 3.GRAVITY 3.CONVENTIONAL SUCTION 4.SAFESUCTION 3a CCR 1q 4.FIBERGLASS 9.FLEXIBLE ,3 4 10.RIOlD PLASTIC SECONDARY CONTAINMENT 90.NONE ❑ 95.UNKNOWN Q 99.OTHER(Sped ); 4M I.STEEL 4,FIBERGLASS 8.FLEXIBLE 464e ❑ 90.NONE ❑ 93.UNKNOWN Q 99.OTHER(SPe9i ); 10,RIGID PLASTIC 1616 PIPINO?URBINE CONTAINMENT SUMP TYPH 4L/c 1.SINGLE WALL Q 2.DOUBLE WALL VI.VENT,VAPOR RECOVERY RAND 90.NONE 4644 VENT PRIMARY CONTAINMENT RISER/FILL PIPE PIPING CONSTRUCTION 1.STEEL 4.FIBERGLASS Q 10,RIGID PLASTIC VRNT SECONDARY CONTAINMENT 1.STEEL ❑ 80.NDNE 99.OTPIER(Sp99i(y) 1611 ❑ 4.PI88ROLA99 10.RIGID PLASriC 90,NONE 99.OTF@R(9peel[y) 44Lar VR PRIMARY CONTAINTIENT I.STEEL 4,P[BERaLAS9 ❑ 10.RIGID PLASTIC 90,NONE 99,OTHER(9pemryr) 4an VR9HCONDARY CONTACVMENT LSTEeL 4.FIeERGLAS3 9 VENT PIPING TRANSITION SUMP TYPE ]SINGLE WALL ]O.RIGID PLASTIC 9D.NONE 99,OTHER(Specuy) 71 RISER PRIA A"RY CONTAINMENT 1,$TEFL 4.FIBERGLASS 2.DOUBLE WALL 90,NONE 464h1 10.1eLOlb PLA371C 90.NONE 99.OTH8R(Spedry) 44ai. RISER SECONDARY CONTAINMEM I.STEEL � q,pIgEROLASS 10.RIGID PLA3T3C 90,NON8 99.OTFfER(Speclly) aL,I FILL COMPONENTS INSTALLED r 1.SPILL BUCKET 3.STRLRER PLATP7BOTTOM PROTECTOR 4.COMAINMENT SUMP 4M�1 VII• CONSTRUCTIOUNDER DISPENSER CONTAINMENT(UDG7 +sla< N TYPE Q 1.SINGLE WALL CON9TRUCRON 41ATER1.4L 1.STEEL 4.FIBERGLASS 2.IXX18LE WALL Q 3,NO DISPENSERS 90.NONE "9e Q 10.RIGID PLASTIC Q ".OTHER 9 41960 VIII. CORROSION PROTECTION - `fplq G STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(9) Q a,IMPRESSED CURRENT Q A.ISOLATION CERTIFICATION: I certlry that this UST s3'afem Ie IX cvmpRM;WAiryPhe hCa�bou SIGNATURE ..Md and tbys the inf0rmudoa provided herein is hvq acrnnte, mad In hll wm Ilaace wit 1 v Rlremea APPLICANT SIGNATURE a DATE f^5-if /7 490, APPLICANT NAME(print) SKr �r 491. PPLI T IT 47E, e+ r UPCF UST-8.1/2 R".(12/2007)