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UNQIIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (Ore Fa cope usq TYPE OF ACTIO (Cheat t91e(tern oBN• Fw a UST c%ane w rclnowl,cany/ere anty tAis lection ad S[] 5, 1. A G/Y.F INFORMATION .M. ❑ 1 NEW PERMIT .RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7'UST PERMANENT CLOSU DATE EXISTING USTDISCOVERED: AL a'� DATE UST PERMAtNEN7I LY CEASED: L FACILITYIItI�ORiifA ETON _ p 7 FACILITY ID k(Agency Um Only) '" /� " a i BUSINESS NAME(Scone as Facility Name wDBA-Doblg&stlrrex3 As) BUSINESS STTE S im. BU ESS NU b CTI'Y IL TANK DESCRII' 41J. TANK IDS TANK MANUFACTURER 431 TANK CONFIGURATION:THIS TANK IS 434. ,J L /- / 1 ❑ I.A STANDALONE TANK C®Pletas Peee Tweseh Aa yi )5 6`7 ��7oL P1yPVe 1F !eP{�tl a a� ONE INA COMPARThfEN1E0UN7i �e�m+k� DATE UST SYSTEM INSTALLED 435, TANK CAPACITY IN GALIANS 416. NUMBER OF COMP iN THE UNIT 437, III. TANK USE AND CONTENTS TANK USE ,.ia.MOTOR VEHICLE FUELING ❑ Th MARW-AFUEEt7NO ❑ Ic.AVIATION FUELING 4 . 0 3.CHEMICAL PRODUCT STORAGE 0 4-HAZARDOUS WASTE Ooa U M) ❑ S.EMERGENCY GENERATOR FUEL DISC"LN01 Cl 6.0TRERGENFAATOR FUEL ❑ 95.UNKNOWN ❑ 99.01TIER( ): �. / (FglfTg PRTREREIRM. [] I.➢IEGIILARIARPADPID Q t9.Mt(IGRADEUNLEADED l6.PREMIUMIINLPADED ❑ 3.DIESEL 0 5.3ET FUEL ❑6.AVIATION GAS 440. 6.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM( : NOKPFfAOLBUM: .0 um I.-- 4400. I(.OTHER NONdEFRALEUM( peel IV. TANK CONSTRUCTION TYPE OF TANK ..I.SINGLEWALL .DOUBLE WALL ❑95.UNKNOWN .-. _...µ- PRBdARYCONTALNMMFNl OI.STEEL ®9.FIBERGLASS ❑6.INTERNAL BLADDER 444e 7.STEEL+ENTERVAt tt3BF6 095.UNiG4DWN 099.OTHER(S ): SECONDARY CONTAINMENT 0 1.STEEL 0 3.FIBERGLASS 0 6.EXTERIOR MEMSRANE LINER 0 7AACKETED we 13 90.NONE 095.UNKNOWN 099.OTHER : ._...__ OVERFILL PREVENTION D LAUDIBLE&VSUAL ALARMS fl7.BALLPLOAT 03.FR.LTl9BF.S1llST-O4F VALVE rl 4-TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 1T, PRODUCT]WASTE PIPING OPONSTRUCTION PIPING CoNSTRUCTroN I.SINGLE WALL. .DOUBLE WALL 99.oT3ER �. SYSTEMTYPE .PRESSURE 2.GRAVITY ❑ 3 cONVLmnoNALSGcnON 0 4 SAFE SUCTION TL3CURt_616ppR 464. PRIMARYCONTAINMENT 0 I.STEEL 15-4.FIBERGLASS D B.nmus E U R9 wlDPLAST4C 0 90.NONE 0 95.UNKNOWN _ ❑99-OTHER(5 ): 4N6 SECONDARY CONTAINMENT 0 L STEEL [14.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464e 0 90.NONE 0 95.UNKNOWN 0 ".OTHER( )' 46u m"BINE CONTAINMENT SUMP TYPE E3 L SINGLE WALL x-pOUBLE wAu. 0 90.NONE .. VL` 1VAVMARC0WR'Y")AND RISER f TFU&PIPIR RIIAIIKG COWM CTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL M .FIBERGLASS 0 In.RIGID PLASTIC 0 90.NONE [199.DIM(Specify): 1. VENT SECONDARYCUNTAINMENT 0 1.STEEL Q-4.FIBBRGLAS5 0 10.RKBDPLASTIC 090.NONE 099 OTHER ISE ). 4N9., VR PRIMARY CONTAINMENT O L STEEL Qq.FIBERGLASS O 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Specify): VRSECOHDARYCO1nAH4MENT ❑ I.STTEL 934.TTBER(TLAES UmmmPLASTIC n9o.NONE 099.OTHBR(SRedk VENT PIPING TRANSITION SUMP TYPE O I.SINGLE WALL 9312.DOUBLE WALL 09D.NONE4b4R RISER PRA(ARYCONTAINMEM O I.STBEL 0.4:FBMGLASs E3 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER 4M'1. wk ETSER SECONDARY CONTAINMENT O L STEEL W-4.FIBERGLASS 1310.mGID PLASTIC ❑90.NONE ❑ 99.OTHER(Spec): FILL.COMPONENTS INSTAI S nn I.SPILL Bucmr a 3.STRIKER PLATPJBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP es VII. UNDER DISPENSER CONTAINMENT(IJA(' CONSTRUCTION TYPE I.SINGLE WALL _ ,DOUBLE WALL 3.NO DSPEFSERS 0 90.NONE_ 4WL CONSTRUCTION MATERIAL ❑ L STEEL yd%.FIBERGLASS ❑ ID.RIGID PLASTTc ❑ OTHER csp�iry) VIII CORROSION PROTECTION $IEEE COMPONENT PROTECTION 2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT 6.ISOLATKIN ' IX. APPLICANT SIGNATURE CERTIFICATION: 1 geGfY pyt thN UST' systew V compe4Hrk with the luaedoos eRMURce emted RW WRt tYe IRbrmetba prev/deA herein a tne, ow MR funto IIRRce with 01 Rleemesm 4W APPLICANT SIGNATURE DATE 3� �� / n P Q{ L 4T1' APPLICANT TITLE &� 0 `- .✓ISI"/ APPLICANT NAME(OPoIG ✓ /n/ +V'Y/� uy('`tl'