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UNIFIED PROGRAM CONSOLIDATED FORM U 6/71 °I UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form Usr) TYPE OF ACTION (Check one item only. Foran UST pennenrnt closurc or removal,complete only this section and Sections 1,II,111,IV,end IX-Mow) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 6.TEMPORARY UST C ® 5.CHANGE OF INFORMATIONLOSURE 7.UST PERMANENT CLOSURE ON STfE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: .-- DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME ISagpe as FACILITY NAME or DBA-Doing Business As) �J{ v 3 5 i • • �t� s CfFY.ST c %/ ' 9 r1 Boa IL TANK DESCRIPTION TANK ID# 432 TANK IVL FACCURER 433 TANK CONFIGURATION:THIS TANK IS 434 7'R/JU) ❑I.ASTAND-ALONETANK SC C ❑2.ONE IN A COMPARTMENTED UNIT, DA US SYI- INSTALLED 435T CAPACIIYMGALLONS 436 eRom fwd mtlrcwuc v �'O 000 NUMBER OF COMPARTMENTS IN THE UNIT 433 III TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE ❑ Ic AVIAIION FUELING 439 ❑ 6.OTHER GENERATOR FUEL Oatlitlo Uu UO ❑ 5.EMERGENCY GENERATOR FUEL[HSC II❑ 95.UNKNOWN ❑ 99 OTHER (S ify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED W 1 b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL I I.OTHERNON-PETROLEUMS i 4406 TYPE OF TANKIV• ,TANK CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ PRIMARY CONTAINMEM ).STEEL . 95.UNKNOWN 443 FIBERGLASS 6.INTERNAL BLADDER 7.STEEL+INTE LINING 095.UNKNOWN 441 SECONDARY CONTANMENT ❑ LS TEEL ®3.FIBERGLASS ❑ 99 � Specify). a4N (] NONE 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 OVERFILL PREVENTION 12-A UDIBLE$VIS 0 9ALARMS WN 2.B ❑9 OTHER S ): M5, 3.FILL TUBE SHUT-OFF VALVE �) 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT L/ p V PRODUCT It WASTE PIPING CONSTRUCTION PIPING CONSTRUC17ON ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED [399.0 THER SYSTEM TYPE S 1PRESSURE ❑ Z.GRAVITY . ... . 460 PRIMARY CON I,AINMEM, ❑3.CONVENTIONAL SUCTION ❑ q.SAFE SUCTION CCR 4z63Yax3) 458 1.STEEL 0 4.FIBERGLASS ❑S.FLEXIBLE ❑ 10.RIGID PLASTIC 4M ❑ Lalttl90. E ❑ 4. UNKNOWN ❑ 99.0THER(Specify): 46/a SECONDARY CONTAINMENT 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 90.NONE ❑ ❑ 10.RIGID PLASTIC 4646 95.UNKNOWN ❑ 99.OTHER(Spenfy): 464, PIPING?IIRBIIYE CONTAR4MENT SUMP TYPE (♦ 1.SINGLE WALT. ❑ 2.DOUBLE WALL 90.NONE VI.VENT,VAPOR RECOVERY464e (VR)AND RLSER/FILL.PIPE PIPING CONSTRUCTION VENT YC NIAMI I.STEEL 0 4.F®ERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Spec*) 4Me VEIN SECONDARY CONTAINMENT U 1.STEEL ❑ 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE4 99.OTHER(Specify) 4Mf VR PRIMARY CONTAINMENT U L STEEL FIBERGLASS 0 10.RIGID PLASTIC 4640 .NONE 99.OTHER(Specify) 464s VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE1 ❑ 99.OTHER(Specify) 469b VENT PIPING TRANSITION SUMP TYPE 11 1.SINGLE WALL 2,.DOUBLE WALL- iMt 90.NONE 46MI RISER PRIv1ARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464j RISER SECONDARY CO" a I.STEEL U 4.FIBERGLASS LJ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 4Mk FILL COMPONENTS INSTALLED I.SPILL BUCKETU 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451.I VII.UNDER'DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE , I.SINGLE WALL ❑2.DOUBLE WALT, ❑ NO DLSPI'NSERS ❑ 90.NONE 469s CONSTRUCTION MATERIAL ❑ 1.STEEL E 4.FIBERGLASS ❑ 10.R1GID PLASTIC ❑ ;'79.OTf1ER(S ) 9696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ■ 6.ISOLATION 448. DL APPIXANTSIGNATURE CERTIFICATION: I certify that th6 UST system is compatible with the hazardous substance stored and that the iuformatioo provided herein h true,accurate, in full to Maes with 1 al menta. APPLICANT SIGNATURE DATE 47], APPLICANT NAME(print) 471. APPLIC T E 472. UPCF UST-B-1/2 Rev.(12/2007)