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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 an UST permanent closure or removal,complete only this section and Sections I,II,121,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J0a I DATE EXISTING UST DISCOVERED: 'ZF! O 430b L FACILITY INFORMATION FACILITY ID k(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As), 3 BUS SS SITE ADDRESS 103CITY Ilb II.TANK DESCRIPTION TANK ID A 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 Qs/6 11M.A STAND-ALONE TANK [ 1 ❑2.ONE N A COMPARTMENTED UNIT. C..I...put,for each enepeenneet in the unit. DATE UST SYSTEM INSTALLED 435 TANK C ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ZO III.TANK USE:AND CONTENTS i�. TANK USE ❑ ia.1,10TORVEHICLE FUELING ❑ Ib.,MI RNAFUELNG ❑ 1c.AVIATION FUELING 439 9.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Induil.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§'-52SI.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUMUNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM (Specify): --dA- J r 440a NOK-PETROLEUK❑ 7.USED OIL ❑ 10.ETHANOL ❑ L OTHER NON-PETROLEUM(Specify): 4406 IV..-TANK CONSTRUCTION TYPE OF TANK I.SINGLE WALL ❑ 2.DOUBLE WALL Cl 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify), 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION LI 1.AUDIBLE&VISUAL ALARMS 132.BALLFLOATU 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.-PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 4.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION l CCR§2 458 ['_ 636fa)O)1 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 464c PIPNGIrURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 461d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINb1EN'T ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.-NONE ❑ 99.OTHER(S eci p 6) 4641 6411 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 6fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464M1 464hi VENT PIPING TRANSITION SUMP NPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. RISER PRIMARY CONTANMENT ❑ I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 461j 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 0 3.STRKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL 02.DOUBLE WALL 03.NO DISPENSERS ❑ 90.NONEjaccurate, CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .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 and in full cam Eance with le al re uirements. APPLICANT SIGNATURE DATE APPLICANT NAME(print) 471' APPLICANT TITLE UPCF UST-B-112 Rev.(1212007)