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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST TYPE OF ACTION (Check one item only For UST permanent closure or removal,complete only this section and Sections I,1%ill,IV,and IX below) 410 ❑ I.NEW PERMIT 3.RENEWAL PERMIT ❑ S.CFIANGE OF INFORMATION ❑ 6.IT'MPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL. DATE USTPERMANENTLY CLOSED: J3an DATE EXISTING USI'DISCOVERED J11b L FACILITY INFORMATION FACILITY 11)p(Agency Use 00y) BUSINFC'4NAMIR(Same asFACILITY NAME orDBA-DoinaBusiness As) , / 3 V it n 9. 9 7n14 BUSINESS SIIE ADDRESS �. 101 CITY m4 Uv r� 5 == k fes-_ II.TANK DESCRIPTION ENVIROMENTALRE TANK IDR 432 TANK MANUFACTURER 433 TANK CONFIGURATION. THISTANK IS DEPARTMENT Ji4 1.ASTAND-ALONE"TANK L lv a�/�r'�-"'� /✓ V 7ti� (L ✓'�^'!`' 2.ONE IN A COMPARTMENTED UNIT, Ce Lem 6n4 on a Por each emn nnmtni in alit it DATE UST SYSTEM INSTALLED 435 TANK CAPACI4'Y IN GALLON 416 NUMBER OF COMPARI'MENTS IN THE UNIT 431 III.TANK USE AND CONTENTS TANK USfi ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic AVIA HON FLELING 449 :V ❑ .1.CHEMICAL.PRODUCT SIORAGE ❑ 4.11AZ.ARDOUS WASTE&,,Ld, Usad Oil) ❑ 5.EMERGENCE'GENERATOR FUEL IHSC 4252s 15(,)7 ❑ 6 OTHER GENERATOR FUEL 00�,95.UNKNOWN ❑ 99.OTHER (SP=4) m9n CONTENTS PETROLEUM. ❑ It, REGULAR Ii NLFADED ❑ Ic.MIDGRADE UNLEADI;D ❑ It.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS V I4' -t-'V „✓ ❑ 8.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM IS t,6 ): 440. NON-PETROLEUM'.❑ 7.USED OIL ❑ 10.P.THANOI. ❑ 11.01-HER NON-PEI'R01-EIJNI(8 p,6N) 1106 IV. TANK CONSTRUCTION TYPE OF"DANK ❑ I.SINGLE W,AII. ❑ 2.DOUBLE WALL 2,95.UNKNOWN 4.13 PRIMARY CONTAINMENT ❑ I.STEEL. ❑ 3 FIBERGLASS ❑ 6.INTERNAL.BLADDER 444 ❑ 7 STEF,I.+INTERNAL LINING 75,UNKNONT' [199.OTHER (S eciN): 444. SECONDARY CONTAINMENT ❑ I S'I'LEL L13.FIBF.RGI.A.SS ❑ ;) L'XTERI0 MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90-NONE ')S,UNKNOWN' ❑99.OTHLR(S vcif): .14Sn OVERFILL PREVEN'T'ION I,AUDIBId!.k VISUAL.AL.:\RMS ❑ 2.BALL FLOAT 3,FILL TUBE SHUT-OFF VALVE 450 ❑ 4 TANK MEETS REQUIRIMEN I'S FOR EXEMPTION FROM OVERFII.1.PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONS'PRUCI'ION ❑ L SINGLL'-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 SYS IEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 12 g O1 )1 ❑ 4.SAFE SL.C-TION It"(R 26)60 1 459 PRIMAR4'CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC' 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Sp,cv y): 464., SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0'DWR(Specify): 464c PIPING!' URBINE CONTAINMENT SUMP TYPE ❑ 1 SINGI.L WALL ❑ 2.DO11131.i WALL ❑ 90 NONE 464d Vt.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VFN'I'PRIMARY CONTAINMENT ❑ I STEEL El 4,FIBERGLASS 0 10.RIGID PLASI IC ❑ 90.NONE Ej 99.OTHER(S,"d') 464, 464e1 VENT SECONDARY CON'fAIN•11ENT ❑ LS'I EEL ❑ 4,FIBERGLASS ❑ 10.RIGLDPLAS'T'IC ❑ 90.NONE. ❑ 99.On IER(SPccily) 464r VR PRIMARY CON'I'AINMEN'f4an ❑ I,$T[HI. 4.Id BERGLASS ❑ 10.RIGID PL,AST'IC ❑ 90.NONE ❑ 99-OTT IFR(Spccify) 4448 _ W•I VR SECONDARY CON'G\INkI L:NI' ❑ I.S'fELI. ❑ 4.FIBERGLASS ❑ 10.RIGID I'LAS'ilC ❑ 90.PONE ❑ 99.OTHER(S1,eci Fy) 4641E 464M11 VENT PIPING IRANSITION SUMP'rYPE D I,SINGLE WALL 0 2.DOURLE WALL 90.NONE 460 RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4 FIBERGLASS U 10 RIGID PI..ASIIC 0 90.NONE. El 99.OTHER(Speoily) m4( 464,1 RISER SECONDARY CONTAINMFNT El L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE CI 99 OTHER(Spcciy) 46A L COMPONENTS INSTALLED El 0 FILL. 1 ❑ 35TRIKGR PLATE/BOTFOM PROI'EC"I'OR ❑ 4.('ON'G\INMENT SUMP 4H.1- VII,UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE, CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4 FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99,OTHER(S ccify) 469b c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODEIS) ❑ 4.IMPRESSED CURRENT' ❑ 6.ISOLATION 44s. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this LIST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full g2g1pliance with legal requirements. APPLICANT SIGNATUR.. APPLICANT NAME(prim) 4n. APPLICANT ITFLE - 471- 1'PCF US"I'-11- Il2 Rev.(12/2007)