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k Id 71)b[09 01 � WF UNIFIED PROGRAM CONSOLIDATED*FO UNDERGROUNDSTORAGETANK r V OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. Form UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Ej 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 45 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME as FACILITY NAME or DBA-Doing Businos As) 3 111 BUSINESS SITE_ADDRE 104 -s 'm CITY T /. (f IL TANK DESCRIPTI�ION TANK ID# 433 TANK MANUFACTURER 433 TANK CONFIGURATION.THIS TANK IS t34 ❑L A STAND-AIONETANK ❑ 2.ONE IN A COMPARTMENTED UNIT. So 86 Seo mNe uac DATE UST SYSTEM INSTALLED +33 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 137 LL-) p0 M.TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(b tl U,N UI) ❑ 5.EMERGENCY GENERATOR FUEL IHSC 135281.5(01 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: E la.REGULAR UNLEADED ❑ le MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 490 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440, NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS i : 9406 IV.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL A 2-DOUBLE WALL El 95.UNKNOWN /43 PRIMARY CONTAINMENT ❑ L STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING 1195.UNKNOWN [199.OTHER (Specify): "a SECONDARY CONTAINMENT El1.STEEL M 3.FIBERGLASS ❑ &EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS ): 445, OVERFILL PREVENTION I.AUDIBLE&.VISUAL ALARMS 2.BALLFIAAT 3.FILL TUBE SHUT-OFF VALVE 45J. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 62.DOUBLE-WALLED ❑99.OTHER 960 SYSTEM TYPE I.PRESSURE 2.GRAVITY ❑ I CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION UlX;R 12636(¢X3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS U 8.FLEXIBLE ❑ I0.RIGH)PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 964, SECONDARY CONTAINMENT ❑ L STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 469b ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): a6k PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464a VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS Ll 10.RIGH)PLASTIC 90.NONE 0 99.OTHER(Speekfy) 4= VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC M 90.NONE Ej 99.OTHER(Specify) 464r 469D VR PRIMARY CONTAINMENT ❑ L STEEL Lj 4.FIBERGLASS 10.RIGID PLASTIC a 90.NONE 99.OTHER(Specify) 4646 46491 VR SECONDARY CONTAINMENT i.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 469h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS HU 10.RIGH)PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4644 964'1 RISER SECONDARY CONTAINMENT M I.STEEL 4.FIBERGLASS 10.RIGH)PLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATEwTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451sT VII.UNDER'DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE LSINGLE WALL ❑ 2.DOU13LE WALL [13.NO DISPENSERS ❑ 90.NONE 969a CONSTRUCTION WE ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGH)PLASTIC ❑ 99.OTHER(Specify) a696'c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ! 6.ISOLATION 498. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herehtls true.accurst¢, and in full compliance with legal reuiremems. 14M.APPLICANT SIGNATUREDATE k.APPLICANT NAME(prinQ 471. APPLICANT E a-, UPCF UST-B-1/2 7)