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q6fl� UNIFIED PROGRAM CONSOLIDATED FORM (( 71 a/O r/ UNDERGROUND STORAGE TANK �T b OPERATING PERMIT APPLICATION-TANK INFORMATION(one toren per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal;complete only this sectionCHANGE OF Iand Sections 1,NL III,FORMATION ,and I below) 430 i.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE RE ON SITE ❑ 8.UST REMOVAL man DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: L FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) 3 BUSINESS ame as FACILITY NAME or DBA-Doing Business As) c BUSINESS SITE ADDRF Lh 103 CITY loa II.TANK DESCRIPTION TANK ID 433 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 # �93.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. '/ (p Com aeon fOMP RT mt inTED UNIT. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS alb NUMBER OF COMPARTMENTS M THE UNIT 43) III.TANK USE AND CONTENTS TAM:USE ❑ ia.2HGTOR PRODUCT LINGSTORAGE ❑ Io.MARINA FLTWAS ❑ is.AVL1fION I-UELING 439': J[�3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mduaa uxd Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC$x5381.5(c)1 alga ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 440 CONTENTS PETROLEUM: ❑ [a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUMUNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS - 44oa ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S xi ) W- NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 44ab ❑ 11.OTHER NON-PETROLEUM(S eci ): IV. TANK CONSTRUCTION TYPE OF TANK i SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN M3 PRIMARY CONTAINMENT ❑ 1 STEEL ❑ 3.FBERGLASS ❑ 6.INTERNAL BLADDER 4a4 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): a44 SECONDARY CONTAINMENT ❑ I TEEL Ll 3.FIBERGLAS$ ❑ 6.EXTERIORMEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S cify): 445, OVERFILLPREVENTION LAUDIII E&VISUALALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 45'_-. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION 460 PIPING CONSTRUCTION `J.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 458 SYSTEM TYPE ❑ LPRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION['-3 CCR S2636WMI 464 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE C195.UNKNOWN CI 99.99.OTHER(Specify): 4% SECONDARY CONTAINMENT ❑ L STEEL LJ4.FIBERGLASS [18.FLEXIBLE (:3 10.RIGS)PLASTIC 464c ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 4694 PIPINGffURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VI.VENT,VAPOR'RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION (Specify) 4641 VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGL A55 ❑ l0 RIGID PLASTIC ❑ 90.N04E ❑ 99.OTHER46411 VENTSECONDARY CONTAINMENT ❑ LSizE- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46ar 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 46as 464 I VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE a64` RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4&1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4Rk 4MM FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKERPLALWVVICOM PROTECTOR ❑ 4.CONTAINMENT SUMP Ociz'c VII.UNDER DISPENSER CONTAINMENT(UDC) c'r r7 'rwE 1.SINGLE HALL ❑ DOUBLE',ALL ❑ 3.NO DISPENSERS ❑ n0 NONECOII4541 CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII::CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIr'ICIAL ANODE(S) El 4.IMPRESSED CURRENT 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full com]RDance with legal re uirements. 4.p APPLICANT SIGNATURE DATE 471' APPLICANTTITLE 412 APPLICANT NAME(print) Rev.(12/2007) UPCF UST-B-1/2