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2O9n35GO9O p. 3 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one to=n w LEST) TYPE OF ACTION (Cbxk cue Ttem only. Fm=UST permanent closun: re or movul,complete only This section and Sections I,If,III,N,and IX below) Oso I.NEW PERMIT 13 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT'CLOSURE ON SITE rl S.UST REMOVAL DATE UST PERMANENTLYCLoSED: a]a DATE EXISTING UST DISCOVERED: 4sob L FACnXrYINFORMATION: FACR;ITY ID#(Agency Use CW(y) I BUSINESS AI91E(Stnc=FACILITYNAM mDHA- iv Budness 3 QGS C . >Il15INF�S SITE D S4 `T� C los CITY Ii TANKDESCRQ'TION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 4N 01.A STANIYAIANE TANK 02.0 EINACOMPAATMFNIEOVNIT. DATE UST SYSTEM WSTAr r en TANK CAPACITY IN GALLONS 06r0f 0Cb 1°"' IN NUMBER OF COMPARTMENTS IN THE UNIT a] III:TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLE FUELING O Ib.MARINAFUELING ❑ Io.AVIATLON FIIELINO _ O9 0 3.CHEMICAL PRODUCT STORAGE E34.HAZARDOUS WASTE(Intludn Vw600) 0 S.EMERGENCY GENERATOR FVFL .](cp ❑ 6-OTHER GENERATOR FUEL Cl 95.UNKNOWN 0 S.EMEMOTER (S ): IBSC 42ml OA CONTENTS PETROLEUM; 0 la.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED aq 0 3.DIESEL Ids S.SET FUEL 0 C AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM S vd NON-PETROLEUM:L3 7.USED OIL ❑ I0.ETHANOL 910a IL07HER MON-PETROLEUMS ): . - IV.`;TANKCONSTRUCTION .. TYPE OF TANK ❑ 1.SMGLE WAIL 0 2.DOUBLE WALL Cl 95.UNKNOWN PRIMARY CONTAINMENT LSTEEL 3.FIHEROLASS 6.MfERNALBLADDFR y16 ].STEEL IKIERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S 444 SECONDARY CONTAINMEM' 0 1.STEEL ❑3.F®ERGLASS ❑6.EXTERIOR MEMBRANE LMER ].TACK61'ED KS ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 44s OVERFILL PREVEMION (.AUDIBLE@VISUAL ALARMS 2BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOREXEMPT]ON FROMOVERFILL PREVEMII]NE VIPMENT V. PRODUCT:/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION L SINGLE-WALLED 2.DO" I.E-WALLED ❑99.OTHFR . SYSTEM TYPE I.PRESSURE 0 2.GRAVRY 3.CONVENTIONAL SUCTION PRIMARY C4-SAFESUCTION ]tRTt 26M(a7(3) 458 ❑ 90.NONE ONTAINMENT U 1.$TEFL 0 4.FIBERGLASS B.FLE%ISLE 11 10.AICD)PLASTIC 464 0 95.UNKNOWN 0 99.OTHER(S 'yJ: SECONDARY COMAMMENi ❑ LS464 TEEC 4.FI5ERGLASS 0 &FLEXIBLE 0 10.1UGIDPLAS'TIC 0 90.NONE 0 95.UNKNOWN Wb 99.OTEff-R(Specify): aMc PIPING?URB ME COMAINT4ENTSUMPTYPE ❑ 1.SINGLE WALL 0 2.DOUBLEWALL 90.NONE VL VENT,VAPOR.RECOVERY4614 R)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENC 0 1.STEEL 4.FIBERGTASSU I D.RIGID PLASTIC Ll 90.NONE 13 99.OTHER(Sp ify) 964e VENT SECONDARY CONTAINMEM (.STEEL U 4.FIBERGLASS 0I0.RIGIDP-` 90.NONE U 99,0THER(Specif5yo) 4 461r VR PRIMARY CONTAINMENT ❑ I.STEEL 0 4.FMERGLASS 13 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 VR SECONDARY CONTAOI61EN1' L STEELLj 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4646 VENT PSUMP TYPE 1.SMOLE WALL ZDOUBLB WALL 90.NONE RISER PRRINGTRANSITION IMARY CONTARVMENT 1.STEEL 4.EBERGLA55 10.RIGID PLASTICu 90.NONE 099.OTHER(Spxify) 464' RISERSECONDARYCONTAINMENT I.STEELU 4.FIBERGLASS 010.ITIGtD PLgSTIC 90.NONE 99.OTHER(Spedfy) 46at FILL COMPONENTS INSTAL LED I.SPILL BUCKET ],STRIKER rL lEa OTTOM PROTECTOR 04.CONTAINMENT SUMP N kz VII.UNDER DISPENSERCONTAINMNT(UDC). CONSTRUCTION MATTYPE OI.SINGLE WALL ❑ 2.DOUBLE WALL O3.NO DISPENSER$ CONSTRUCTION MATERIAL I.STBEL 4.FIBERGLASS ❑ 90.NONE 4694 _ ❑ 10.R[Gm PLASTIC 99.OTHER($ e9i ) 4696s VQL CORROSIONPROTECTION.. . - - - STEEL COM PONENTPROTECTION ❑ 2.SACRIFICLAL ANODE(S) 0 4.IMPRESSED CURRENT 0 6.ISOLATION 44s. )R. APPLICANT-SIGNATURE CERTTPTCATTON: I e the this T s m v mpatlble with the hazardous substanee tared and and Da wl 1 al that the iofosmatlov provided hercb ln true,a4:cun/e,n c uiremevta. APPLICANT SIGNATU DATE 7 4'ro APPLICANT NAME APPLICANTTITLE - 4]t UPCF UST-11-1/2 Rev.(12/2007)