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ra UNIFIED PROGRAM CONSOLIDATED FORM ULl �jy UNDERGROUND STORAGETANK zz OPERATING PERMIT APPLICATION-TANK INFO I (One f/o m U G TYPE OF ACTION (Check one item only. Fm an UST permanent closure or removal,complete only this section and Sections I,H,IU,IV,and IX below) <jo ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION lCX�J71 O 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 91-rUST REMOVAL DATE UST PERMANENTLY CLOSED: 43m DATE EXISTING UST DISCOVERED: 43ob I. FACII TTY INFORMATION F ACILITY #(Agency Use Only) ) (� _ I N Sartre as ACILICY or BA-Doi BUSts As) 3 " � l b PALON � 3 SINES IN CITYmoa � jc-ril)L- II.TANK DESCRIPTION 432 TANK ACTURER 433 TTAAN.KCONFIGUS 434 S t{5�.ASTAND-�l ( J a (n �('�L ❑2.ONE IN A IT.ICONTEUN�TS SYSTEM INSTALLED 435 wdc TANK CAPACITY IN GALLONS <36 NUMBER OF COMPARTMENTS IN THE UNIT 431 III.TANK USE AND CONTENTS ❑ 1&MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bkledm Used Om Q 5.EMERGENCY GENERATOR FUEL(ESC JID81.5(c)I ❑ 6.OTHER GENERATOR FUEL H)'5.UNKNOWN ❑ 99.OTHER(Specify): 43% PETROLEUM: ❑ is.REGULAR UNLEADED Q Ic.MIDGRADE UNLEADED QIb.PREMIUM UNLEADED 410 Q 3.DIESEL Q 5.JET FUEL Q 6.AVIATION GAS Q S.PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM IS Yccj : 440 NON-PETROLEUM:Q 7.USED OI. ❑ 10.ETHANOL El 11.OTHER NON-PETROLEUMS 440b IV. TANKCONSTRUCTION TYPE OF TANK .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMEM Url.STEEL Q 3.FIBERGLASS u0 .INTERNAL BLADDER 441 ❑ 7.STEEL+ FIBERGLAINTERNAL LINING 095.UNKNOWN ❑99.OTHER S . a44a SECONDARY CONTAINMENT ❑ 1.STEEL Q 3. SS Q 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ RAMBLE ❑ 95.UNKNOWN Q OTHER ): 05. OVERFILL PREVENTION 1.AUDILE 8 VISUAL ALARMS 2.BALL FLOA7 3.FILL TUBE SHUT-OFF VALVE 432 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED Q 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ I.PRESSURE Q 2-GRAVITY Q 3.CONVENTTONALSUUTION U4.SAFE SUCTION 23CCRg2636(aR3)l 458 PRIMARY CONTAINMENT' ❑ L STEEL Q 4.FIBERGLASS Q S.FLEXIBLE ❑ 10.RIGID PLASTIC 4M ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHIM'Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXELE ❑ 10.RIGH)PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN Q 99.OTHER PIPINGn URBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL Q 2.DOUBLE WALL Q 90.NONE a61d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS I0.RIGH)PLASTIC 90.NONE 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT Q 1.STEEL U 4.FIBERGLASS 0 IO.RIGIDPLASTIC 90.NONE 4Me1 ❑ 99.OTHER(Specify) 1641 Wit VR PRIMARY CONTAINMEll U I.SMEL Q 4.FIBERGLASS ❑ I0.RIGH)PLASTIC Q 90.NONE U 99.OTHER(Spm*) 464, VR SECONDARY CONTAINMENT u 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGH)PLASTIC Q W.NONE LJ 99.OTHER ISpaify) 64el VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE a69h� RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGH)PLASTIC 90,NONE l 99.OTHER(Specify) 464' 4641 RISER SECONDARY CONTAINMENT U 1.STEEL LJ 4.FIBERGLASS u10.RIGID PLASTICU 90.NONE El 99.OTHER(Specify) 4641 FlLL COMIPONENTS INSTALLED 11 1.SPILL BUCKET LJ 3.STRIKER PLATFJ90170M PROTECfOR 4.CONTAINMEM$UMP 4*40 VII.UNDER DISPENSER CONTAINMENT.fI1RC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL Q 2.DOUBLE WALL Q 3.NO DISPENSERS Q 90,NONE 469+ CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGH)PLASTIC ❑ 99.OTHER IS ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) Q 4.IMPRESSED CURRENT [16.ISOLATION 448. Ix APPLICANT SIGNATURE CERTIFICATION: fy that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accuratq in fuH co G ce wlth 1 al re uiremeob. APPLICANT SIGNA r DATE 4H). APPLICANT NAME((unit °li" APPLICANT TITLE 4n. co � tA/l C37n. C, U✓ UP'CE UST-H-UL iur(1Dl�lT