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UNIFIED PROGRAM CONSOLIDATED FORM U1? UNDERGROUNDSTORAGETANK Jui, \� �� U OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. F a UST permanent closure orremoval,complete only this section and Sections L II,III,IV,and IX below) 030 ❑ I.NEWPERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE CE,INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE UST REMOVAL DATE UST PERMANENTLY CLOSED: Cf oZ-p a3a DATE EXISTINGUST DISCOVERED. .. - 430b L FACILITY INFORMATION FgCII.ITY ID!l(Agency Use Only) BUSINESS NAME(Same as FACH,ITYNAME or DBA_Doing Business As) �_ 3 13USINFSS SITE ADDRESS z L103 CITY ioa II.TANKDESCRIPTION TANK ID# 432 'I'/IN[t MANUFACTURER 433 TANK CONFIGURATION: THIS TANK ISF2�4N ❑LONE I NA ALONECOMER TANK ��"�'Y/f�_� 12.ONE IN A COMPARTMENTFJ7 UMI. DATE UST SYSTEM INSTALLED 435 TANK CAPACITYINGALNS 436 `fora .a 0 00FC 7 III.TANK USE AND CO TANK USE la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 [:1 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I°dl Uand oil) ❑ 5.EMERGENCY GENERATOR FUEL Fix§2528r.s(q ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,0THER(S 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ 10.MIDGRADEUNLEADED ❑ Ib.PREMMMUNLF.ADED 440 ;Y5.DIESEL ❑ 5.JET FUEL ❑ &AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUMIS 4aoa NON-PETROLEUM:Ll7.USED OIL ❑ 10.ETHANOL ❑ it.OTHER NON-PETROLEUM(SpecifyI. 9a� IV. TANK CONSTRUCTION ,19 TYPE OF TANK ❑ 1.SMGLEWALL DOUBLEWALL ❑ 95.UNKNOWN Qa3 PRIMARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+INTE AL LINING ❑95.UNKNOWN ❑ 99.OTHER (S i 444a SECONDARY CONTAINMQTC ❑ L STEEL .FBEAGLASS ❑ 6.EXTERIORMEMBRANELINER ❑ 7.JACKETED Ons ❑ 90.NONE 95.UNKNOWN ❑99.OTHER Speci : OVERFII,LPREVENUON I.AGGIBLE&VISUAL ALARMS 2BALLF15AT FHL TUBE SHITI'-0FF VALVE 452. ❑ 4.TANK MEETS REQUIl2FJr¢NTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPMG CONSTRUCTION ❑1.SINGLE-WALLED 2. UBL&WALLED 099.OTHER aw SYSTEM TYPE a( b.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[xt CCR§2636(a)(3)) 458 PRIMARY CONTAR464EN'I' ❑ 1.STEEL 4.FIBERGLASS 0 S.FLIOUNCh ❑ IO.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTEER(Spaa fy): 464a SECONDARY CONTAINMENT ❑ 1.STEEL . .FIBERGLASS ❑ 8.F7 FXIBI p ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a64c PIPINCf1VRBBJE CONTAIN1viFNT SUMP TYPE ❑ I.SINGLE WALL .DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VEM'PRIMARYCONTAMIrfENT ❑ L SIEEL BERGLASS ❑ IO.RIGID PLASTIC ❑ 90_NONE ❑ 99.MIER(Spe ify) 46Ce VENT SECONDARYCIC 'AINMENf ❑ I.STEEL BERGLASS ❑ IO.RIGID PLASTIC �e1 ❑ 90.NONE ❑ 99,OTHER(Specify) 4641 VR PRIMARY CONTAINMEIJ'1 ❑ 1.SI'EEI, FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify) 464g VR SECONDARY CONTAAIMENT ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLA511C0 90.NONE ❑ 99.OTHER(Specify) 46491 469h VENT PRIMARY CONTAINMENT TYPE ❑ 1.SINGLE WALL DOU13LEWALL ❑ 90,NONE RISER PRIMARY CONTAINA�NT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASDC ❑ 90.NONE ❑ 99.OTHER(Specify) RISER SECONDAKYCONTARJMENT ❑ I.STEEL 4.FIBER1LASS4641 ❑ lo.RIGH)PLASTIC ❑ 90.NONE ❑ 99.01TiER(SP-*) 464L FILL COMPONENTS INSTALLED .SPILLBUCKET ❑ 3.STRIKERrL tWBOTTOMPROTECTOR 464c1 ❑ 4.CONTAINMENT SUMP 451ac VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.3TEEL .FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99-OTHER Specify) g69y< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION .SACR�ICW,ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this USC system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in toll compliance with legal mquirements. CANE 4IqNATURE DATE aro oAl APPLICANT NAME(print) 4D. APPLICANT TITLE. , p ,t a72 / 6tr ` L UPCFUSr-B-I2 Rev.(1712007)