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,I UNIFIED PROGRAM CONSOLIDATED FORM ��Q�3�lzsZ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One foml pet UST) TYPE OF ACTION (Check one item only. Foran UST pem4anent clPEosure or removal•complew only(his section and Sections 1,11.III,IV,and IX ❑ 1.NEW PERMIT ❑ U1 RENEWAL RMIT ❑ 5,CHANGE OF INFORMATION '! 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL T y DATE UST PERMANENTLY CLOSED: 410i DATE EXISTING LIST DISCOVERED: °)Ub T 1. FACILITY INFORMATION FACILITY ID S(Agency Use Only) BUSTNESS ME(Same as FACILITY1NAME orDBA-Doing Eusit g!5 As) 3 �w 5 fa�J(a Co 4r haus BUSINESS SITE DRESS 103 CITY (f j Iw II.TANK DESCRIPTION TANK ID 0 43 TANK MANUFACTURER 433 TANK CONFIGURATION:71118 TANK IS 41, '434 I ASTAND-ALONE TANK Iy �"Sa� IIe G/'}/- 2.ONE IN A COMPA RTMENTED UNIT, Cmaawt.ane pane fnrwe'cu,np..t in Ik"At DA INS A LEp 436 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS IN'11-IE UNIT n 111,TANK USE AND CONTENTS TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA DUELING ❑ 10,AVIATION FUELING 434 ❑ 3.CHLMICALPRODUCI-STORAGE ❑ 4.HAZARDO1JSWASTE0,.Iwb U.dOil) ❑ S.EMERGENCYGENERAT012FUEL0tSC;25281-5(c)) 6.OTHER GENI3RnTI R FUEL K95.UNKNOWN ❑ 99.OTHER M(Specify): °on CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED ❑ Ic.MIDORADL4 UNLEADED ❑ IS PREMIUM UNLEADED on ❑ 3.DIESEL ❑ S.JET KIEL ❑ 6.AVIACION QAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ci I: {/i R Ow iVon NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i'): o@b IV. TANK CONSTRUCTION ' TYPE OF TANK ❑ I,SINGLE WALL ❑ Z.OOI)BLC.WALI. 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS 6.INTERNAL.BLADDER 444 ❑ 1,SFEEL+INTERNAL LINING X95.UNKNOWN ❑ 99.OTHER (Specify): 444+ SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS 6,EXTERIOR MEMBRANE LINER ❑ 7.IACKETP,D 445 10,NONE � 95.UNKNOWN ❑99.OTHER(Seeif): 4454 OVI7RFI LI.PliP.VENTiON ❑ 1AIJDIBLE&l'ISIJAt.nI.ARMS 2.BALL FLOAT 3.FILLTUBE SHUT-OFF VALVE 452, ❑ 4,TANK MEETS RIFQUIREMEN'FS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 469 SYSTEMTYPE ❑ I,PRESSURE ❑ 2.GRAVI'IY ❑ S.CONVEN'i'IONALSLICTION ❑ 4.SAF6SUCTION 2l C7R42636(.XA 454 PRIMARY CONTAINMENT ❑ 1.S'I'L•GL ❑ 4. CLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE [] 95.UNKNOWN ❑ 99.0THER(Spccifyl: 464. SECONDARY CONTAINMENT ❑ 1.STEEL 4.PIBLRGLASS ❑ N.FI.EX1BLE ❑ 16.RIGID PLASTIC T 4646 ❑ 00.NONE: ❑ 95.UNKNOWN ❑ 99.OTHf:R(S ccify): 4"4 PIPING/'NRBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2 DOUBLE tVALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VEIN'PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBEROI.ASS ❑ Io.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Sp..*) 464. 46,10 VENT SECUNDA RY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 13 99.OTHER(Specify) 4(Wr 4mH VR PRIMARY CONTAINMENT D 1 STEEL 4.FIBERGLASS IO.RIGI PLASTIC ❑ 91).NONE 99.OTHER(Spccify) 41A4 Kd I VR SECONDARY CONTAINMENT ❑ I,STEEL 4,FIBERGLASS l0.R1GIU PLASTIC ❑ N).NONE ❑ 99.OTHER(Specity) 4o4h 444Ft Yl-'NT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 4w.. RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46Q 464k1 FILL COMPONENTS INSTAL LED ❑ I.SPILLBUCKE'C 3.5`TRIKFRPLATFAOTTOMPROTECTOR ❑ 4.CONTAINMENT SUMP 451n"e VII. UNDER DISPENSER CONTAINMENT(UDC_)_ _ CONSTRUCTION'IYPC• ❑ I.SINGLE WALL ❑ 2.DOUBLE WALT. ❑ 3.NO DISPENSERS ❑ 90.NONE 4694 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S if) 4626-4 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODF(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION; I certify that Ibis UST system is compatible with the hazardous substance stored and that the Information provided herein is true,accurate, and In ILII compliance 4rith le al requirements. APPLICANT'SIGNATUR Lr �-�✓- ' "" -.- -_ 4: NQS l.�l- 4]0. �uL f - �- APPLICANT NAME(pnnt GTI" APPLICANT TITLE A 472' UPC'£UST-13-I/Z /� �� UA,(12/2007)