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UNIFIED PROGRAM CONSOLIDATED ffRM UNDERGROUND STORAGE TANK l r 3U1nx) OPERATING PERMIT APPLICATION-TANK INFORMATION(one roan per usT) TYPE OF ACTION (Check one item only. Foran UST permanent closure m removal,compkte only this Sechan od Sections 4 4 IB,IV.and IX below) 430 C) 1.NEW PERMIT 0 3.RENEWAL PERMIT 0'S CHANGE OF INFORMATION It, : . -J. 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SIRE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 630. DATE EXISTING UST DISCOVERED: 4Jpb L-FACILITY INFORMATTON FACILITY ID#(AgMCy USC Only) _ _ / 1. 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busies;As) // _ / 3 BUSINESS SITE ADDRESS�/,7/"� „/ X03 CITY Boa f �v ZcirST�i9ric o C >O� _IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 THAW CONFI(URATION:TMS TANK IS 4.34 d Ed..A STAND-ALONE TA /1 NK y� DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III TANKUSEANDCONTENTS TANK USE CK Ia.MOTOR VEHICLE FUELING O Ib.MARINA FUELING O le.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE pod.da the(M) 0 5.EMERGENCY GENERATOR FUEL(BSC 423261A()I 0 6.01'HERGENERATOR FUEL 0 95.UNKNOWN 0 99 OTHER (S 439. CONTENTS PETROLEUM: 9 Ia.REGULAR UNLEADED ❑ IC MIOGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 0 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS O s.PETROLEUM BLIND FUEL 09.OTHER PETROLEUM S 41p NON-PETROLEUM:0 7.USED OIL 0 10.ETHANOL 0 11.OTHER NON-PETROLEUMS 4406 IV. TANKCONSTRUCTION. TYPE OF TANK 0 LSINGLEWALL 2.DOUBLE WALL 0 95.UNKNOWN 443 PRIMARY CONTAINMENT 0 1.STEEL t&3.FIBERGLASS 0 6.INTERNAL BLADDER a44 0 7.STEEL+INTERNAL LINING 0 95.UNKNOWN 099.OTHER 'specify): sot. SECONDARY CONTAINMENT 0 1.STEEL 3.FIBERGLASS 0 6.EXTERIOR MEMBRANELK4EIR E 7.JACKETED u5 0 90.NONE 95.UNKNOWN 0 99.OTHER ): Mb OVERFILL PREVENTION 1.AUDIBLE d VISUAL ALARMS I RALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION [11.SINGLE-WALLED R L DOUBLE-WALLED 0 99.OTHER 46D SYSTEM TYPE I.PRESSURE 07-GRAVITY 03.CONVENTIONAL SUCTION L, 4.SAFE SUCTION I23 CCR¢2636(a3)1 4% PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0S.FLEXIBLE 0 10.RIGID PLASTIC 464 0 90.NONE 95.UNKNOWN 0 ".OTHER(Speco): 464. SECONDARY CONTAINMENT 0 1.STEEL �4.FIBERGLASS 0 S.FLEXIBLE 0 10.RIGID PLASTIC "Na 0%.NONE 95.UNKNOWN 0 99.OTHER(Speci(y): 464c PIPINGTTIIRBINE CONTAINMENT SUMP TYPE JR 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE 4646 Vi:VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION- VENT PRIMARY CONTAINMENT U 1.STEEL X 4.FIBERGLASS El 10.MGM PLASITC 0 90.NONE ".OTHER(Specify) 464e Al VENT SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS El 10.RIGH)PLASTIC 90.NONE ".OTHER(Spe.;y) 4uf .e n VR PRIMARY CONTAINMENT I.STEEL ok d.FIBERGLASS 0 l0.R(Gn]PLASTIC 0 90.NONE E3 99.OTHEIt(Specify) 4649 VR SECONDARY CONTAINMENT ETI STEEL 4.FIBERGLASS LJ 10.RIGID PLASTIC OL90.NONE 99.OTHER(SpeGfy) 464a 464h1 VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL Pq 90.NONE a6ai RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS HU 10.KRIM FLASITC U 90.NONE 0 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT I.STEEL JR 4.FIBERGLASS 10.RIGIDKASM 90.NONE 0 99.OTHER(Spaify) 464k FILL COMPONENTS INSTALLED I.SPRL BUCKET 3.STRBCER PLAT&&JT[OM PROTECTOR /.CONTAINMENT SUMP 44694151ac VII.UNDER DISPENSER CONTAINMENT(UM CONSTRUCTION TYPE 1.SINGLE WALL 0 2.DOUBLE WALL [13.NO DISPENSERS ❑ 90.NONE 46%1 CONSTRUCTION MATERIAL 0 1.STEEL pq 4.FIBERGLASS 0 10.RIGID PLASTIC 0 99.OTNER(S ) 4696-c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) [14-IMPRESSED CURRENT 6.ISOLATION 418. ITC. APPLICANT SIGNATURE CERTIFICATION:I cortify that thb UST.ysh b eompatlh&a w Ih the haa.door rohrtaoce rb.ed o W thot the Ioformotbo p.ovtded hereto is true,a¢t'rAtq mnd in fill compkimec V APPLICANT SIGNATURE DATE Oro. f APPLICANT NAME(print) 611" APPLICANTTITLE 47' UPCF UST-B-112 Rev.(1212W/)