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AL Alk IFIF,D PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One Corm per USI) 'TYPE OF ACTION (Check ane item only. For UST"permanentclosure or removal,complete only this s4xlion and Sections I,It,IR,IV,and IX below) 471 ❑ I.NEW PERMIT 3,RENEWAL PERMIT a 9.CHANGE OF INFOR A ON ❑ ti.IT.MPORARYUSTCLOSURE ❑ 7.UST PERMANENT CLOSURE ONSITE S,LI ST REMOVAL 4D DATE USP PI-AMANENTLY CLOSED: d50n I DATE ENISTING USTDISCOVERED: J5, 1. FACILITY INFORMATION I`ACILI"LY IU N(AgenrP lien'ally/ /- I O� BUSTIVFQ'Z NAA4Rp(Smne as FACILITY NAME or DBA-Doing Business AS) _ ) BUSINESS SITE ADDRESS � 103 CITY f i I 11.TANK DESCRIPTION Z-{rte 'I ANK U)N T.A�`9!f*71e3;32 DANK NIA+NUFACIURER 10 T.ANR CONFIGURATION. -I HIS IS - 2 434 !!//77 VV OO[[!!// LASTAND-ALONE9.ANK 2.ONE IN A COMPARTMENTED UNIT. Co Ivmonv 24,a mmanmvat in Bm.b DATE UST SYSTENI NSTALLED 435 TANK CAPACITY IN GALL.ON+S') d36 NUMBER OF COMPARTMENTS IN TME UNIT 437 (i ,v I.4,.-„✓ v4.rtJ �.- /u V o cc Ill.TANK USE AND CONTENTS TANK USE 0 in.MOTOR VEHICL6l UELING Q Ih.MARINA FUELING 0 1,Avix io,,ATLINO 439 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS W ASTCIIndud.LhM0,1) 0 5.EMERGENCY GENERATOR FUEL IHSC§252915(1)1 0 6.OTHER GENERATOR FIA L OT-95.UNKNOWN 0 99.OTHER (Specify): 4344, CONTENTS PETROLEUM. 0 I a.REGULAR UNLEADED 0 1¢.MIDGRADE UNLEADED Q Ib.PREMIUM UNLEADED 440 0 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS V/3N 1L 12'�"�s✓ O IL PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (5 m'6 : NON-PrTROLEU\I:0 7.USED OIL 0 10.ETHANOL _ ❑ 11 u'I'HP.R NONAETROLCI;M fSpcciH+ 440h IV. TANK CONSTRUCTION TYPI:Gl--I ANI, . 0 I.Sl WILE.\MALL 0 2.DOUBLE WALL 9i.UNKNOWN 443 PRIMARY CONTAINMENT 0 I.STEEL ❑ 3.FIBERGLASS 0 h,INTERNAL BLADDER 444 0 ].STEEL+INTERNALUNING gL 9i UNKNOWN 0 99.OTHER (5lecif Y. 444" SECONDARY CONTAINMENT Q I.STP EI_ 03.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKS"('ELY 44S Q 90.NONL1 95.GNRNOWN ❑99.OI'H HER E"eci 445n OVERFILL PREVENTION 1.AIIIIBL E&VISUAL ALARMS 2.BALI.FLOAT Q i.FILLTUBE SHUT-DI`F VALVE 452 0 4 TANK MITTS.REQUIREMENTS FOREXEMPTION FROM OVERFILL.PRF.VE.NTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSFRUCI ION ❑ LNINGLL-WALLED 0.DOURLE-WALLED 099,OI"HER gnu SYSTLMTYPE 0 I.PRESSURE 0 2.C)RAVI'I'Y Q 1CONVI?NITIONALSUCTION 0 4.SAFESUCTION nCcJ263«1X3)) 4M PR).MARY CONTAINMENT Q 1.5'IEEL 0 4.FIhER6LASS 0 8,FLI'.XIBLE Q 10.RIGID PLAN I E- 'IM Q 90.NONE 0 95.UNKNOWNQ '49.OTIIFRIS •iC): 464v SECONDARY CONTAINMENT Q 1.STEEL ❑ 4 FIBERGLASS 0 a.FLFS7I Q 10 RIGID PLASTIC 046 Q 90 NONE Q 05,UNKNOWN 0 99,OTHI:R(Spccilv): qw4 PIPMG"IL'RBINF CONTAiNS1IlN'r SC NIPTYPP. ❑ I SINGLE WALL 0 2 DOTMI.II W NL_L 0 90 NONE 9c6 VL VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION YeNTPRIM.ARYCONTAINMI-Xf - Q I STEEL Q 4 1'IHErWLASS Q w MOIOPLAS'11C O ",NONE Q 99 0IHLR(9p f,) M. a6ael VENI SECONDARY CONTMNML',NI 0 L STEEL 0 4.FIBERGLASS 0 10,RIGID PLASTIC 9o.NONE a 99.OTHER(Specify) 464E 4lWn VR PRINIARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Spocify) 4", _......... 4fAI VR SEC'ON'DARY CONTAINMENT 0 1.STEEL C1 4,FIBERGLASS ICFRi.RIGID PLASTIC El 90.NONE 0 99,OTHER(Specify) 461h 44,1+1 VEN I'PIPING TRANSITION SUNIP'I'1'PL'. 0 I,SINGLE WALL in 2.DOUBLE WALL 90.NONE 464,. RISER PRIMARY CONTAINMENT' U 1.STEEL Lj 4.FIBERGLASS LJ 10.RIOID PLASTIC U 90.NONE Lj 99.O)TILK(Specify) 10 1, 484,1 RISER SECONDARY CONTAINMENT I.STEL In 4.FIBERGLASS 0 10 RIGID PI-.ASTIC 90.NONE 99.OTHEE(Spuily) i64k Imwl FILL COMPOV NTS INS'PAL I_ED ❑ 1.SPILL BUCKET 0 1 STRIKFrt PL ATJ1301'1'0M PROTECTOR 0 4 CON'T,VkaIFNII-WMP 45k, VII.UNDER DISPENSER CONTAININIENT(UDC) CONSTRUCTION I'Y111 _._0 I SINGLE WALL 0 . DOUBLE WAIL Q i NO DISPINSI'.RS Q 40.NONE 4096 CONSTRUCT"LUN M%,rr rtl:\I. 0 1STER Q 4 FIBERGLASS 0 1 fl.RIGIDPIASTIC 0 4,7.OTTIIRIS :dB'. 46m '1 _ Vlll. CORROSION PROTECTION STEEL COMPONI N I PROfR-1 ION 0 2.SACRIFICIAL ANODES) 0 4 IMPRF.SSF.D CURRENT ❑ 6.ISOLATION ax, IX. APPLICANT SIGNATURE CERTIFICATION: 1 cerfifly that this US F system is compatihie with IIIc hazardous substance stored and that the information provided herein is true,occurale, and In aIj!.gLpIisncc with legal requirements. APPLICANT S IGNATU DATF. APPLICANT NAME.(print) 472.^j �D` hMj71- APPLiC.4N'I'TI'TLE �A�` 1. 1� Y^_' .4,A l t. t;PCF 1ST-li- V2 Rev.(122007)