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001196 I UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (one Tam3 per usT) TYPE OF ACTION (Checkane item only. For a USTclosure or removal.complete only this section and Sectlons 1.1(111,lY and 1X below) 4M. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE Q 7 UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4M% I DATE EXISTING UST DISCOVERED: 43)h I. FACILITY INFORMATION FACILITY ID p(Agency Use Only) - 1. - BUSINESSNAME(Sameas Facility Name or DBA DoingBmi:e As) ; BUSINESS ADDRES in I CITYSIN la `(-L, TI. TANK DESCRIPTION TANK ID flTANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ,,., p_ r�� (I.A STAND-ALONE TANK Cmml4eleere pgafaeed o2_6010 433. © ❑2.ONEINA COMPARTMENTED UNIT --v m tl-ffi-WL DATE U T YSTEM TALLED 435. 1 TANKMIN IN GALLONS 436. NU�F COMPARTMENTS IN THE UNIT 4U. M. TANK USE AND CONTENTS TANK USEIs.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1..AVIATION FUELING 439. M❑3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(wU ONO [15.EMERGENCY GENERATOR FUEL BLSCIMSI-X ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN L 99.OTHER(Specily): 439. CONTENTS PETROLEUM. ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED It.PREMIUM UNLEADED 410. ❑ 3.DIESEL ❑ 5.TET FUEL ❑6.AVIATION GAS _ ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHERPETROLEUM(Sperify): 440. NON-PEFROLEUM El 7.USED OIL ❑ 10.ETHANOL ❑ 1[.OTHER NON-PETROLEUM 440h IV. 'TANK CONSTRUCTION TYPE OF TANK ❑ I.S3NOLE WALL 2.DOUBLE WALL El 95.UNKNOWN M3. PRIMARY CONTAINMENT ❑ 1.STEEL 7.FIBEROLASS [36.INTERNAL BLADDER i4l ❑].STEEL+INTERN LINING ❑ 95.UNKNOWN ❑ 99.OMER(Specify); 444+ SECONDARY CONTAINMENT ❑ I.STEEL A 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ J IACKET'L+D _ ---µs' [3 90.NONE 10,95.UNKNOWN ❑99.07HBRS i p Mh OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑2.BALLFLOAT 3.FIILTUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERF L EVENTIONEQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTIONt❑y�I�.SINGLE WALL 2.DOUBLE WALL 99.OTHER 4% SYSTEM TYPEI.PRFSSURE ❑ .GRAVITY Q 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 2l CCR 636( 3) 45R PRIMARY CONTAINMENT ❑ L STEEL A4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4M. ❑ 90.NONE 95.UNKNOWN ❑99.OTHER Rectify): 464' SECONDARY CONTAINMENT ' TEEL ",Q/.FIBERGLASS ❑8.FLEXIBLE [I10.RIGH)PLASTIC 169h ❑90.NONE S.UNKNOWN ❑99.OTHER(Specify): 4Ma PIPINGfrURBINE CONTAINMENT SOME TYPE t.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641 VI. VENT,VAPOR RECO Y(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 STEEL A 4.FIBERGLASS ❑ HI RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): yM•j VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Miak NONE ❑ 99.OTHER(Specify): 4640 VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ UL RIOM PLASTIC ❑90.NONE ❑ 99.OTHER(Specify): 4=1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC �Wft NONE ❑ 99.OTHER(Speciry): Moa _ 4Mh1. VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL ❑2.DOUBLE WALL CK90.NONE RISER PRIMARY CONTAINMENT II STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Sped(y>: 11 164'1. RISER SECONDARY CONTAINMENT ❑ 1.STEELA4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE ❑ 99.OTHER(Spedry): IMkI, FILL COMPONENTS INSTALLED1.SPILLBUCKSr e3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP VII. UNDER DISE NSER CONTAINMENT C) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE4997 469a CONSTRUCTION MATERIAL 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGH)PLASTIC ❑99.OTHER(Specify) g5gc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANO S) ❑4.IMPRESSED CURRENT 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION:I eerlify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is true, accurate,and in full compliance with requirements. DATE 4'Ip. L APPLICANT SIGNATURE Fl V P_ APPLICANT NAME(print) 4J1' APPLICANTITItE UPCF UST-B Rev.(12/200'7) 1/2 www.ualdate.org �r "�J