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• Cl UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK I I OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) ammal TYPE OF ACTTON (Check one item only. For aUST pemmneat ckislae or removal,complete only this section and Section,L II,II,IV,end IX below 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION O 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410` I DATE EXISTING UST DISCOVERED: 4J0b I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) _ _ 1 &7111 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) _ 3 Zr/rST deair/ BUSINESS SITE AD RESS Im A/ !e'S'T Li9�/g cITv �i�c4f��e.,J i� IL TANK DESCRIPTION TANK m k 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1.A STAND-ALONE TANK O L Lf4 62.ONE IN A COMPARTMENTED UNIT. one 6trearLI ct.flaait DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT / 437 III.TANK USE AND CONTENTS' TANK USE f$I Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1..AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTEM.N"UaJo ) ❑ 5.EMERGENCY GENERATOR FUEL[BsC f2928L5(c)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 4w I3 3.DIESEL ❑ S.IET FUEL ❑ 6.AVIATION GAS ❑ &.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ' 44oa NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL El 11.OTHER NON-PETROLEUM $ i : Nab W. TANKCONSTRUCTION TYPE OF TANK 0 1.SINGLE WALL2.DOUBLE WALL 95.UNKNOWN 43 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4N ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Spemft Nea SECONDARY CONTAINMENT ❑ 1.STEEL �(3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED NS ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 5 . ): Nb OVERFILL PREVENTION 1.AUD®LE&VISUALALARMS U2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION p CCR 12636(.X3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL R 4.FIBERGLASS ❑ 8.FLEXIBLE 15 I0.RIGID PLASTIC 464 ❑ 90.NONE [Q95.UNKNOWN ❑ 99 Specify): `tMa SECONDARY CONTAINMENT 1-] 1.STEEL 4.FIBERGLASS 11 FOM- 0 10.RIGID PLASTIC L.1 4646 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER( ): 464c PIPINGrrURBINE CONTAINMENT SUMP TYPE 50 1.SINGLE WALL 2.DOUBLE WALL El 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 13 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464e 46N1 VENT SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 10,RIGID PLASTIC IQ 90.NONE Q 99.OTHER(Specify) *If 4Nft VR PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 95.OTHER(Specify) 461, 464al VR SECONDARY CONTAINMENT 0 I.STEEL Q 4.FIBERGLASS Ej 10.RIGID PLASTIC IQ 90.NONE 0 99.OTHER(Specify) ONh 46fi1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2.DOABLE WALL 0 90.NONE 4641. R6ER PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) 464j 464'I RISER SECONDARY CONTAINMENT LSTEEL 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR Ia 4.CONTAINMENT SUMP 451. 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.RIGIDPLASTIC ❑ 99.OTHER(S ) !414 VIII. CORROSION PROTECTION ST EEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATIONIX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the herardous substaace stored end that the information provided herein is true,accura , ad in fall caeali ith ui nts. APPLICANT SIGNATU _ DATE 47n J/ APPLIC NAME 471• (P � � APPLICANT OL NiIL 47L UPCF UST-B-1/2 Rev(12!2007)