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X11 ' `LD UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(o.rotor per UST) RTYP OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 1.NE W PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J0i FDATE EXISTING UST DISCOVERED: 4Mb I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 11 1 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busincss As) 3 MA-0 Tutft IAM W1 BUSINESS SITE ADDRESS 103 CITY IN ;T� 11'S W . �(aSevhl F u�A ?'CCA U.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANKNFIGURATLON: THIS TANK IS 434 .A STAND-ALONE TANK 1-Pr ps - go COWTNOMENT 5-)Wj ❑2.ONEMACOMPARTMENTEDUNIT. 4' cw.. 6xrech eain0e.t DATE UST 5 S M INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMRARTMENTS IN THE UNIT 437 2 2s> >J l III.TANK USE AND CONTENTS TANK USE le.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(l dulw Ua Di0 ❑ 5.EMERGENCY GENERATOR FUEL[HsC 123381.3(c)] ❑ 6.OTHERGENERAT FUEL ❑ 95.UNKNOWN ❑ ".OTHER(S 'fy): 43% CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ IL PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 490a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL I I.OTHER NON-PETROLEUMS 4406 /''� �I�V. :TANK CONSTRUCTION TYPEOFTANK ❑ Q- LSINGLEWALL �c.u..UBLE WAIL 095.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN- 099.OTHER S 414a SECONDARY CONTAINMENT ❑ L STEEL MERGLASS ❑ 6.EXTERIOR MEMBRANE LPIER 7.JACKETED "5 ❑ 90 ONE ❑ 95.UNKNOWN ❑99.OTHERS ): "U OVERFILL PREVENTION .A(JDIBLE&VISUALAIARMS .BALL FLOAT 3.FILL TUBE SHUT-0FE'VALVE 432 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED UBLE-WALLED ❑99.OTHER 450 SYSTEM TYPE RESSUR12 ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION in CCR 1M36(a1(3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL IBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 454 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S1eciTy): 46G SECONDARY CONTAINMENT ❑ L STEEL 43-T.-FIBERGLASS ❑ 8.FLEXIBLE ❑ T0.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLEWALL .DOUBLE WALL ❑ 90.NONE 46ad VL VENT,VAPOR RECOVERY(VR)AND RISER/FII L PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC NEI 99.OTHER(Specify) 46ac 464 1 VENT SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGH PLASTIC 90.NONE 99.OTNER(Spaify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ l0.RIGIDPLASTIC ❑ 90.NONE 99.OTHER(Spccify) 1Wg VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Spe fy) a64M1 46461 VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGH PLASTIC 90.NONE 99.OTHER(Specify) 464j 461'1 RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGH PLASTIC 90.NONE 99.OTIJER(Spedt'y) 4 k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a.c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 3.NO DISPENSERS CONSTRUCTION MATERIAL. 1.STEEL FIBERGLASS. ❑ 90.NONE 469a ❑ lO.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ff 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, ftand in PoII cem nce with legal requirements. CATV SIGNATURE DATE ` aro. APPLICANT NAME(print) 1^'I 471' APPLICANT TITLE 4n. �t�- EJI t UPCF UST-B-1/2 Rev.(I22007)