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001196 • 7 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 1 OPERATING PERMIT APPLICATION-TANK INFORMATION (One tam porusT) TYPE OF ACTION (Check owe item only, For o UST closure or removal,complete only this section and Sotons 1.11.111,IV and IXbelaw) 430 ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE 7 UST PERMANENT CLOSURE ON SITE B.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430aDATE EXISTING UST DISCOVERED: 4RI6 I. FACILITY INFORMATION FACILITY ID M(Agency Use Only) - - BUSINESS NAME(Sameae FacilityN_- JnQAdomeor DBA Doing Bmineu As) BUS SS RESS to. I CI� H. TANK DESCRIPTION TANK IDN 432 TANK ACTURER 433.' TANK CONFIGURATION:THIS TANK IS 434. TANK 4llDD I.A STAN6ALONE to 2.ONEWA COMPARTMENTED ED UNIT wCamepylennct In wa&mrRerh DATf'u7sy,,,,,ST0,4,114STALLED 431 TANK C ACTTY IN GALLONS 435 1 PIUMBE F COMPARTMENTS IN THE UNIT 46s III. TAN USE ANA CONTENTS TANK USE le.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ to.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inaudms/4m Ul) ❑ 5.EMERGENCY GENERATOR FUEL DISC i2R81.5(0) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Speafy): CONTENTS PETROLEUM. /Q la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED P°3.DIESEL ❑ SAHT FUEL ❑6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑9,011 ER PE 1R0LEUM(Specify): 490s__ NON-Pmouum 0 7.USED OIL ❑ METHANOL Cl 11.OTHER NDWPETROLEUM(S xify): 4406. IV. TANK CONSTRUCTION TYPE Or TANK ❑ I.SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN M3. PRIMARY CONTAINMENT p I.STEEL 3.FIBERGLASS ❑ 6.I1,1IERNAL BLADDER ❑7.STEEL+ ALLINING ❑95.UNKNOWN ❑ 99.OTHER(Speci�: SECONDARY CONTAINMENT ❑ 1.ST86L 3.FIBERGLASS ❑ 6.EXMIORMHMBRAN6 LINER ❑7.JACKEM ❑ 90.NONE 95.UNKNOWN ❑99.OTHER i8peaft 445a OVERFILL PREVENTION ❑ L AUDIBLE S,VISUAL ALARMS ❑2.BALL FLOAT 3.FILL TUBE SHUTOFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXBMPfION FROM OVERILL REVHNTION EQuIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIING CONSTRUCTION ❑ 1.SINGLE WALL EIL2.DOUBLE WALL ❑99.OTHER _ W. SYSTEMTYPE .PRESSURE 2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCRT2636(63) 45R PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ S.FLE)OBLE ❑ 10.RIGID PLASTIC 464. _❑ 9D.NONE 95.UPECNOW_N ❑99.OTHER(Specify): 4� SECONDARY CONTAINMENT ❑ 1.STEEL �4,PIBeRGLA33 ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑99 OTHER(SpeutY): 9610 PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4646 VL VENT,VAPOR RECOVERY(VR AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 STEEL 4.FIBeRGLASS ❑ 10.RIGH)PLASTIC ❑ 9o,NONE 0 99.OTHER(Spmify): 4Wb VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ f0.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 4M11 VR PRIMARY CONTAINMENT ')r1.STEEL ❑4.FIBERGLASS ❑ to.MOLD PLASTIC ❑90.NONE ❑ 99.OTHER(Spac*): VR SECONDARY CONTAINMENT '[3I.ST88L ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC JK 90.NONE [399.OTHER(Spedfy): 46µj VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL [I 2.DOUBLE WALL ,i 90,HONE - RISER PRIMARY CONTAINMENT ]!1-1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spai[y): 4641 469'1. RISER SECONDARY CONTAINMENTT❑ 1.STEEL ❑ 4.FIB13RGLASS ❑ 10.RIGID PLASTIC x90.NONE 99.OTHER(Specify): 4646j FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATFl80TLOM PROTECTOR 4.CONTAINMENTSUMP VII. UNDER DISPENSER CONTAINMENT CONSTRUCTION TYPE 1.SINGLE WALL ❑2 DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑99.OTHER(Specify) I696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 6.ISOLATION 44a M APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system Is compeUble wkh the harardom substance stored and that the brformation provided harem b true, accuse and in full compliance with menta. APPLICANT SIGNATURE DATE _ _ 4m, APPLICANT NAME(Pr 471' APPLICANT YrrLEdn. UPCF UST-B Rev.(12/2007) 1/2 www.sualdm.org ' s-4��