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>,/14.! t y-> 11124 /14 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, III, IV, and IX below) 430 ❑ L NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE. ❑ 7. UST PERMANENT CLOSURE ON SITE & UST REMOVAL . DATE UST PERMANENTLY CLOSED: 430. I DATE EXISTING UST DISCOVERED: /a 7�•I5� 43M I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) fAv�' _ _ I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Ce/f eA-Sfo-f< o s ; �4 A . ¢�ArRo 4 So-/ZS79,aA .v ;. it ✓f Ar r.�3//. e0Al:/, BUSINESS SITE ADDRESgoat,S / 103 CITY l 1 II. TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THISTANKIS 434 RI.ASTAND-ALONETANK 2.ONE M A COMPARTMENTED 4A 1C,,,;W4 A I10WA Com lde one for each mmanmenl in the emit DATE UST SYSTEM INSTALLED 435 TANY CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 w OI0 -G9 III. TANK USE AND CONTENT'S TANK USE [I ]a. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ to. AVIATION FUELING 439 (] 3. CHEMICAL PRODUCT STORAGE n, 4. HAZARDOUS WASTE PndudA Used Oil) ❑S. EMERGENCY GENERATOR FUEL [HSC ¢152813(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ to. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL R 9. OTHER PETROLEUM S Wi :G A/N 411d- 440. NON -PETROLEUM: F, 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 44W IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING 095. UNKNOWN ❑ 99. OTHER (S edify): 444. SECONDARY CONTAINMENT ❑ 1. STEEL [13. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (S i 4459 OVERFILL PREVENTION ❑ I. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 6 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE -WALLED ❑ 2. DOUBLE -WALLED ❑ 99. OTHER 469 SYSTEM TYPE ❑ I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SA FE SUCTION ED CCR 42636(.$3)] 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGlI'URBINE CONTAINMENT SUMP TYPE ❑I. SINGLE WALL Ll 2. DOUBLE WALL [1 90. NONE Wd VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4. FIBERGLASS ❑ IO. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER(Spwify) /648 464.1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS I0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (�ipwify) 464r 464fl VR PRIMARY CONTAINMENT ❑ ].STEEL El 4, FIBERGLASS ❑ 10.RIGIDPLASTIC;NONE El 99 OTHER(Specify) 4618 464 I VR SECONDARY CONTAINMENT ❑ 1. MEL ❑ 4. FIBERGLASS El IQ. RIGID PLASTIC 0. NONE J3 99. OTHER (Specify) 464h 4Mhl VENT PIPING TRANSITION SUMP TYPE rl I. SINGLE WALL 0 2. DOUBLE WALL 090. NONE 4641. RISER PRIMARY CONTAINMENT LIL STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC LJ90. NONE ❑ pv 46( �TC 469' I RISER SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS EI 10. RIGID PLASTIC ❑ 90.NONE ❑ W. OTHER (Spxify) 4644 I 464k1 FILL COMPONENTS INSTALLED ❑ I. SPILL BUCKET ❑ 3, STRIKER PLATEMOTTOM PROTECTOR ❑ 4. CONTAI MENT SUMP 451a -c VII. UNDER DISPENSER CONTAINMENT (U CONSTRUCTION TYPE ❑1. SINGLE WALL El DOUBLE WALL El 3. NO DISPE El 90. NONE 46% CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE - 470. � APPLICANTNAME(pr' ) / 471' 'It APPLICANT TITLE 472 - 11 /�/. / - A'e. 4A /<t 4, hW 7 6,,.(i /ref' .✓T UPCF UST -B - 1/2 %001 VOO Rev. (12/2007)