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1��rxy� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK Z(k'Iai OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,l, only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ,0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4'o4 1 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Onty) ©C9 �F 7 1;X BUSINESS NAME(Same as FACUM NAME or DBA-Doing Busiceas As) 3 r1.��90 f BUSINESS SIJP7AD SS��'!� /y_ ,/-.V4`) IID crry /`��P�f 4e /.r.L�`, Ip4 IL TANKDESCRIPTIONN TANK ID# 432 TANK MANUFACTURER T 433 TANK CONFIl3VRAT10N:TRIS TANK Is 434 ^❑.1..16NE IN MANE TANK u�..VNE M A COMPARTMENTED UNIT. e¢orc fare4rhmv in au wuk DAT YJ,!S'[EM INST 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPAR S IN THE UNIT 437 L�1 e[E71 III.TANK USE AND CONTENTS TANK USE Crl..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6qulo UwOn) ❑ 5.EMERGENCY GENERATOR FUEL[HSC g252aL5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER IS ify): 439. CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED [3 1.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 4.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44p4 NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL ❑ II.OTHER NON-PETROLEUMS i : p)pb . TANK CONSTRUCTION TYPE OF TANK ❑ LSINGLEWALL Er2.DOUBLEWALL [3 95 UNKNOWN 443 PRIMARY CONTAINMENT 1,STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qqq ❑ 7.STEEL+INTERNALLINIJC ❑ 95.UNKNOWN ❑ 99.OTHER (S 444. SECONDARY CONTAINMENT ❑ 1.STEEL .F®ERGLASS ❑ 6,EXTERIOR MEMBRANE LINER ❑ 7.1pCKEIIR) 445 ❑ MIA 0.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 4q� OVERFILL PREVENTION LAUD®LE&VISUAL ALARMS 2.BALL FLOAT ,FIL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFIL PREVENTION EQUIPMENT V. PRODU WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DO 'D ❑99,OTHER �p SYSTEM TYPE .PRESSURE ❑ 2. RAVTfY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CCR$2636(.X3) 458 PRIMARY COMAINMEM 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90,NONE ❑ 9 OWN ❑99.oTHER(SlR 'Y): 469. SECONDARY CONTAINMENT ❑ L STEEL 4.F®ERGLASS ❑ 8.FLEXIBLE ❑ In.RIGID PLASTIC 4646 ❑ 90.NONE ❑ .UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90,NONE 4694 VI.VENT,VAPOR RECOVERY(VR),AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90 NONE 99,OTHER(Specify) 46k VENT SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS !0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) f 4648 VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RfGm PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464, VR SECONDARY CONTAINaffM ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ,NONE 99.OTHER(Sp-fy) 4M1 VEIN PIPING TRANSITION SUMP TYPE GLE WALL 2.DOUBLE WALL .NONE �i. 4Mi. RISER PRIMARY COMAINb¢M 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE U 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT 1.STEEL 4.FIDERG SS 0 10.R[GID PLASTIC 90.NONE 99.OTHER(Specify) 4Mk 464k1 FILL COMPONENTS INSTALLED LSPILLBUCKEI' 3.STRIXERPIATFIBOTTOMPROTECTOR .CONTAINMENT SUMP 451st 1 GLUNDER'DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE E WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATERW, Ltr 1.STEEL ❑ 4.FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 99,OTHER( 'fy) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICULL ANODE(S) [1 4.IMPRESSED CURRENT .ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,a4xnrate, and in full wm lis sim less]re ulremenh. , APPLIC TU � / DATE `✓U 470. AP (Print ©`l `LA"Q 471. APPLICAN'TrTLE � r' 4rc y UPCF UST-B-1/2 Rat.(I „r