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o UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK �Q7 (� �q OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo per s / TYPE OF ACTION (Check one item only. For an UST petmment closure or removal,complete only this section and Sections I,R,III,IV,and IX below) 439 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J0e1 DATE EXISTING UST DISCOVERED: 4306 L FACQ.TTYINFORMATION FACILITY ID#(Agency Use Only) _ _ L 1 BUSINESS NAME(Smica= s FACRSTY NAME or DBA-Ibing Business As) J ,f///t°CJ SO �' BUSINESS S1T�_PDD 5 103 CII'YS. O� �- 104 S!5`� IL TANK DESCRIPTION ,d TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THISTANK35 434 ❑1.A STAND-ALONE TANK T 3 y86 3 T� s c o ❑ 2.ONE INA COMPARTMENTED UNIT. DATE U T SYS M INST ED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 00 M.TANK USE AND CONTENTS TANK USE ❑ ia.MOTORVEMCLE FUELING ❑ Ib.MARINA FUELING ❑ IC.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE 0r Uw al) ❑ 5.EMERGENCY GENERATOR FUEL[BSC 12528LN01 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED IE le.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440. NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM S i : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL a 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STL+INTERNAL LINING ❑ 95.UNKNOWN El99.OTHER 5 4Me SECONDARY CONTAINMENT ❑ L STEEEEL ®3.F03ERGLASS ❑ &EXTERIOR MEMBRANE LINER El ].JACKETED a5 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS ): 445. OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.'PRODUCT/.WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED E 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 0 LPRESSURE ❑ 2.GRAVITY ❑ 3.00NVENTIONAL SUCTION ❑ 4.SAFESUCT[ON 23CCR12636(.X3) 436 PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy): 464' SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(specify): 46k PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464( a64n VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 1p 90.NONE 99.OTHER(Specify) 464g 46491 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC M 90.NONE 99.OTHER(Specify) 464h 964h1 VENT PIPING TRANSITION SUMP TYPE FI 1.SINGLE WALL 2.DOUBLE WALL E 90.NONE 4641 RISER PRIMARY CONTA94MENT Lj 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC stj 90.NONE U 99.OTHER(Specify) 464i 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS E3 10.RIGID PLASTIC 90.NONE C3 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATPIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS [190.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT E 6.ISOLATION 449. W. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stared and that the information provided herein b,frue,ucurate, and in full compliance with lecal renuirements. APPLICANT SIGNATURE - DATE J �� / Aro' (O LY O APPLICANT NAME(print) .r, J/// a71" APPLICANT 47). Clv J /S UPCF UST-B•1/2 Rn`... 2007)