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UNIFIED PROGRAM CONSOLIDATED F t�� V ^ l C L8t UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) TYPE OF ACTION (Cheek one item only. For an UST pamenenI closure or removal,complete only this section and Sections I,II,UI,IV,and IX below) 430 I'NEW PERMIT C 3.RENEWAL PERMIT C 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE OST PERMANENTLY CLOSED: 4308 DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ - 1 BUSINESS NAME(Seine as FACILITY NAME or DBA-Doing Business As) 3 Y,-> BUSINESS SITE ADDRESS 103 w\ oZ 1 4J- MITL 'RUC Crry Yvl �[ C-VA IL TANK DESCRIPTION TANK 1D# 432 TANK MANUFACTURER 43i T�AT,yCONFIGUaAT10N: THIS TANK IS 434 tb ^�- (_O k; '(41 N 10 ENT !![--r-I@I�C�..T�aAee��STANn-ALONE TANK <-- TA OS 1� g�� SuLultoN ac . INAfCwO�ARTMENfEDuImft� DATE UST SY TEM INSTALLED 435 TANK CAPACITY INGALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 M.TANK USE AND CONTENTS TANK USE kCaT2.MOTOR VEHICLE FUELING C Ib.MARINA FUELING C lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Iisc a ua Oil) ❑ 5.EMERGENCY GENERATOR FUEL ❑ 6.OTHER GENERATOR FUEL [MC 9252813(c)1 ❑ 95.UNKNOWN ❑ 99. IS � ): 4194 CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 41p NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 8406 IV. TANK CONSTRUCTION TYPE OF TANK CI.SINGLE WALL .DOf1'LE WALL [1 93.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.INFERNAL BLADDER 44q C 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S a44n SECONDARY CONTAINMENT .1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ISM' 445 C 90.NONE ❑ 95.UNKNOWN C 99.GTHER(S - ): 4458 OVERFILL.PREVENTION UDIBLE @ VLS 0 ALARMS .BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIFMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED UBLE.WALLED ❑99.OTHER 860 SYSTEM TYPE RESSURE 2.GRAVITY C 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION Ill CCR 636(.X3)1 458 PRIMARY CONTAINMENT ❑ 1.$TEFL Lp ±FIBERGLASS Ll8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE _ 95.UNKNOWN E3 99.017HER(SP ify): �a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN C 99.OTHER(Specify): g6gs PIFING?URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL UBLE WALL C 90.NONE 964d VL VENT,VAPOR RECOVERY(VR);AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PIUMARY CONTAINMENT 1.STEEL 4.FEERGLASS LJ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC a6aO ❑ 90.NONE 99.OTHER(Specify) a64g VR SECONDARY CONTAINAENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONEEl 99.OTHER(SPaify) 464h VENT PIPING TRANSITION SUMP TYPE I.SINGLE WAL 2.DOUBLE WALL 90.NONE 16M1 RISER PRIMARY CONTAMAENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC Us 90.NONE 99.OTHER(Specify) 464j RLSERSECONDARY CONTAINMENT L STBEL 0 4.FIBERGLASS 010.RIGID PLASTIC 90.NONE 99.OTHER(Spsify) 4Nk FILL COMPONENTS 4ST,1 I 11FI.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑3.NO DISPENSERS ❑ 90.NONE 4% CONSTRUCTON MATERW, 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b.� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION C 2.SACRIFICIAL ANODE(S) C 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is campadble with the hazardous subspace stored and that the information provided herein is true,accurate, and in full compliance witb legal requirements. PLIC SIGNATUREDATE ( I S I 478 APPLICANT NAME(print) NI'1� S 411, APPLICANT TITLE On. 7Rte)I �EN7 UPCF UST-B-1/2 Rev.(1212007)