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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form pesUsT) T)NE OF ACTION (Chect-one nein ails For o UST closure or removal,canplere ailr tins section and Secnow I,LL III,T(;andLY beloo) 430 ❑ LNEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OFINFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERhLANENT CLOSL7RE ON SITE 8.UST REMOVAL DATE UST PMLA14ENTLY CLOSED: 430a. D.ATEEMSTINGUSTDISCONTRED: 43M I. FACILITY INFORMATION FACILITY ID=(Agency Use Onh) - - BUSAIESSyNyAh�(Smne/a's Fo�n7rp�nre or DH-1-D�ng Bus s . 1 3 BUSINESS SITE ADDRESS 193 CTI Iw II. TANK DESCRIPTION TANK ID= 432 TANK MANUF'ACTC 433 TATDi CONFIGURATION:THIS TANK IS 434 --A o5lS$4f'!. (NL�L-/tel ❑ L.VEBNA l�'On8?RYrn1ENTED LT7rr v Nc�e er�p� CWII LlYleala Wesal DATE UST SYSTEM STALLED C 435 TANK CAPACITY IN GALLONS 43dR�1BFR OF COh1PARTTlENTS IN TF3E UF1IT 43' Za 10 O III. TANK USE AND CONTENTS TANKUSE $la MOTOR VEFIICLE FUELING 0 ]h MARINA FUELING L3Ic..Al14TIONFUELING 439 �j 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Ralalu Uwd W) ❑ 5 EhffiRGENCYlRII RATORFLBL[MC§2528151x)1 _ ❑ 6.OTHERGENERATORFLBL 0 95 UNKNOWN ❑ 99.OTEER( d,). 43% CONTENTS PETROLELTI ❑ In REGULARUNLEADED 0 le MIDGRADEIJNLEADED W-Ib PRE,11UMU9LE.ADED 440 0 3 DIESEL .0 5 JET FUEL 6.AVLAIIONG.AS 0 8 FSIROLEUMBLENDFLBL 0 9.OTHER PETROLELRIi(5 ' ,). 44h. NON-PETROLEUM 0 7 USED OIL ❑ 10 ETHANOL II.OTHERNON-PETROLEUMi ih) 440,. IV. TANK CONSTRUCTION TYPE OF TANK O 1.SINGLE WALL 2 DOUBLE WALL _ -[1 95.UNLNONN 443. PRINLARY CONTAINMENT 1 SfE 1. �GLASS 0 6.IISPERNAL BLADDER 4u. 7.STEEL+INIERNALLINING 0 95UNTNOtiN 0 99.OTHER(S '). 444. SECONDARY CONTAINMENT 0 L STEN. tFIBERGLASS 0 6.ETTERIOR h4ABRANE LINER ❑ 7.JALIZETED N5 0 pq 90.NONE ❑ 95 LNk NOUN 0 99 OTHER(S -). 448 OITRFI.L PREVENTION 0 1.AUDIBLE&ITSUAi..ALARMS 0 2.BALL FLOAT PL 3.FILL TUBE SHLTa rFF VALVE 4`=. 4.T.ANKhH•USRE LUMIENTSFORE%MWnONFROMOI PREI'ENTTONE tMIENT V. PRODUCT/WASTE PIPING CONSTRUCTION _PRING CONSTRUCTION 1 SINGLER:ALL 2DOLBLE WALL 0 99 OTHER SY SIHM TYPE O31.PRESSURE 2.GRAiTTY 0 3.LYIMMMONAL SUCTION 0 4 SAFE SUCTION 23 RR e6* 3) 45& PRUJARY CONTAINMENT 0 1 STEEL �4 FIBERGLASS 0 8.FLEITBLE 0 10 RIGIDPLASTIC ❑ 90 NONE 95 LTANORN 0 99 OTHER(SPecd,,). 464 SECONDARY CONT.AINhffiNT E3 1.STEEL 4FUQRGLASS 0 8.m EIJBNP [I IQ RIGID PLASTIC 4" 0 90 NONE 0 95.UNISNORN 0 99.OTEER(Rpe4t 4We. PIPING TURBINE CONTAINMENT SLIIP TYPE 0 1 SINGLE lK%LL p 2.INDLBLE WALL 0 90 NONE 464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINA ENf 0 L STEEL 1p 4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(SPecdy)- , VENT SECONDARY CONTAINMENT ❑ L MERL In 4 FIBERGLASS 0 10.RIGIDPLASTTC 0 90 NONE 0 99.OTHER(SPecifi-) 461t1 VRPRTMARY CONTAINMENT ❑ 1.STffi. 14 4.FIBERGLASS 0 10.RIGIDFLASTIC 0 90 NONE ❑ 99.OTBER(SP"dl) 1 VR SECONDARY CONTAINMENT 01.STEEL 0.4 FIBERGLASS 010.RIGIDPL.ASfIC 090 NONE 099.OTBER(Sfecit't) j VENT PIPING TRANSITION SUMP TYPE OI.SINGLEWALL q2DOUBINWALL 090.NONE RISERPRI4ARY CONTAINMENT 'jL 1 STEEL 0 4 FIBERGLASS ❑ 10 RIGIDPLASIC [3 90 NONE 0 99 OTHER ISpecd)I J6y 1 RISER SECONDARY CONTAINMENT 0 1 STEEL tj�4 FIBERGLASS ❑ 10 RIGIDPLASTIC 0 90 NONE 0 99 OTBER(Spec&) FILL COMPONENTS INSTALLED I.SPILL la 3 STRIMPL\TErBOTTOMPROTEITOR Od 4.CONTAIRv RTTSMIP VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I SINGLE WALL 2 DOUBLE ❑ 3 NO DISPENSERS 9D.NONE 469x. Q_-_- _�. -_.-_-- ._-.__p.-__...__...__-_ - CONSTRUCTION MATERIAL. ❑ L STBE. FX 4.FIBERGLASS 0 I0.RIGIDPLASTIC ❑ 99.OTHER(Specify) 6 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 '_SACRIFh1AL.ANODE(S) ❑ 4 IIPRESSEDCRMENT QIC.ISOLATION 41F II►, APPLICANT SIGNATURE CERTIFICATION: I certi 't t this UST system is compat le with the hazardous substance stored and that the information pro3ided herein is true, acatra e a it in full carnal R e a uirements. APPLICANT SIGNATURE DATE G' '41 APPLICANT NAME(print) k-� 4,1 APPLICANT Ind r 4, UPCF UST-B Ree.(1220P7)-12 {�� .unidomorg