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a UNIFIED PROGRAM CONSULT V A ILL) V"MIVr UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) 430 arid Sections 1, 11, IORMATION below) or removal, complete only this sO15 TYPE OF ACTION (Check one item only. For an UST permanent closure CHANGE OF INF ® 3. RENEWAL PERMIT ❑ 1. NEW PERMIT _ _ ❑ 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL 43M 6. TEMPORARY UST CLOSURE 43NDATE EXISTING UST DISCOVERED: DATE UST PERMANENTLY CLOSED: I. FACILITY INFORMATION FACILITY ID H (Agency Use Only) 3 BUSINESS NAME (Same as FACILITY NAME Or DBA -Doing Business As) _ r/ flifole Vitic'{f !/ S..{tst.. �>;w x .! ✓I rr4Awr F / COh( Gw-Sfe'f-c o ': BUSINESS SITE ADDRES 103 CITY II. TANK DESCRIPTION 434 431 TANK MANUFACTURER 433 TANKCONFIGURATION: THISTANKIS TANK IDH PA STAND-ALONE TANK 2. COMPARTMENTED UNIT. ONE M A 44A //aw1W A rrI✓ Com late one ew for euL e9mrRmwl m,he wft. 415 TANK CAPACTTY IN feel 5 nue 4l6 NUMBER OF COMPARTMENTS 1N "TH$t1NIT DATE UST SYSTEM INSTALLED rw SOQ '�� III. TANK USE AND CONTENTS TANK USE ❑ in. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ le. AVIATION FUELING 52 Rers(c xd Oil) .� ❑3. CHEMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE tOil) [1S. EMERGENCY GENERATOR F ]g. 439 I g39s ❑ 6. OTHER GENERATOR FUEL [195. UNKNOWN [399. OTHER (Specify): ❑ Ib. PREMIUM UNLEADED 1 CONTENTS PETROLEUM: 11 ]a. REGULAR UNLEADED ❑ I.. MIDGRADE UNLEADED ❑ 6. AVIATION GAS ❑ 3. DIESEL ❑ 5. JET FUEL �s ❑ S. PETROLEUM BLEND FUEL 9. OTHER PETROLEUM (S eci :. O/e-Ac bA �Sr�- ! r 4/a NON -PETROLEUM: J. 7. USED OIL ❑ IO.ETHANOL 4 b ❑ II.OTHER NON -PETROLEUM (S i : W. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN V14 PRIMARY CONTAINMENT ❑ I. STEEL ❑ ....... ❑ 6. INTERNAL BLADDER ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER IS 'fY): 444e 045 SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90.NONE ❑ 95. UNKNOWN ❑99.OTHER (S ci I. AUDIBLE&VISUAL ALARMS ❑ 2. BALL FLOAT 3. FILL TUBE SHUTAFF VALVE 452 OVERFILL PREVENTION EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT ❑ 4. TANK MEETS REQUIREMEMSFOR V. PRODUCT /WASTE PIPING CONSTRUCTION 460 PIPING CONSTRUCTION ❑ I.SINGLE-WALLED ❑ 2. DOUBLE -WALLED ❑ 99.OTHER ❑ I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE $UCI'ION CCR §t636(rJp) 453 SYSTEM TYPE PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4M 46ge ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHEA(Specify$ ❑ 4. FIBERGLASS ❑ B. FLEXIBLE ❑ 10. RIGID PLASTIC 464b SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specl11 464e 464d PIPINGITURBINE CONTAINMENT SUMP TYPE ❑I.SINGLE WALL ❑2. DOUBLEWALL ❑90.NONE RISER / FILL PIPE PIPING CONSTRUCTION VI. VENT, VAPOR RECOVERY (VR) AND VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spcefy) 46ge1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC [390. NONE ❑ 99 OTHER (Sp«ify) 61F 464H VR PRIMARY CONTAINMENT ].STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE 99.OTHER (Specify) 964, 464 VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Spxify) 464h 445. �M` ❑ 2. DOUBLE WALL 90. NONE VENT PIPING TRANSITION SUMP TYFE I. SINGLE W ALL 90. NONE ❑ 99.O: ER(Specify) omen 1-1 a FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 4641 46Ij1 RISEK PKIMNK i I, V �. ��......... _F1 90, NONE (] 99. OTHER (Specify) ,I... VII. UNDER DISPENSER CONSTRUCTIVIII. CORROSION PROTECTION 448. ❑ 4. IMPRESSED CURRENT [16. ISOLATION STEEL COMPONENT PROTECTION ❑ z. sncRIFICIAL ANODE( . APPLICANTSIGNATURE CERTIFICATION: I certify That this UST system is compatible with the hazardous substance stored and that the information provided herein a true, accuralee, 47 and in full com H 'th It trPhents DATEq APPLICANT SIGNATURE I' / - �-� 472. �- 471. APPLICANT TITLE - -- APPLICANT NAME (PUW)�7� `T�/,(IL�„q/.Q �"�j2i/✓G!P/r'✓L / UPCF UST -B-12 Rev. (122007) Rev. (12/2007)