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b� L j)1, UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND GE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form UST) TYPE OF ACITON (Check one item only. Fm M UST pcnmou ckJsure or removal, ❑ L NE W PERMIT 3.RENEWAL PERMIT cmnplela poly this se 0m and Scall-1,II,-III,IV,and IX beipw) 6.TEMPORARY USTCLOSURE 7.UST PER MANENT CLOSURE ON SITE 0 S.CHANGE OF INFORMATION UA'I'I,UST PERMANENTLY CLOSED' +39, S-UST REMOVAL DATE EXISTING UST DISCOVERED: 479b L re n FACILITY INFORMATION FACILITY ID N(ASency UOlYl BUSINESS NAME(Sem;es FACILITY NAME or DBA-)ping Business As) BUSINESS SITE ADDRESS J 168 8 McK'n 07 CITY IM TANK ID NG7 II.TANK DESCRIPTION TANK MANUFACTURER 4D TANK CONFIGURATION: THIS TANK 1$ I.A STAND-ALONE TANK +w µe XFRXES Cl 2.ONE IN A COMPARTMENTED UMI'. DATE UST SY M INSTALLED JJs TANK CAPACITY M GALLONS 476oR ft 'n1101m� NUMBER OF COMPARTMENTS M THE UNIT 4J7 TANK USE I.,M0T00.VEHICLE FUELING III.TANK USE AND CONTENTS 7.CHEMICAL PRODUCT STORAGE Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 4.j 0 95 UNKNOWN OWN WASTE 161dWe Uwtl oil) O S.EMERGENCY GENERATOR FUEL If=1252a1.$c)I 439 ❑ 6.01 GENERATOR FUEL 0 95.UNK RDOU W'. PETROLEUM: 0 Ia.REGULAR UNLEADED ❑ Ia MIDGRADE UNLEADED 0 'OTHER S i ): U9a /1 $I 7.DIESEL ❑ S./E7 FUEL ❑ Ib.PREMIUM UNLEADED Np ❑ 6.PETROLEUMBLIND FUEL 09.OTHER PETROLEUM 06.AVIATION GAS NON-PETROLEUM;0 7,USED OIL S I 'HN 10.ETHANOL I I.OTHER NON-PETROLEUMS i �-� IV. TANK CONSTRUCTION `Jsb It'PE VF'fANK ❑ L SINGLE W.LL '.pOUBLE WALL LJ i�r'RIMA 4l'CONTAINMENT 0 I.STEEL 95.UNKNOWN 7.FIBERGLASS 6.INTERNAL BLADDER N7 L_- 07.STEEL*INTERNAL LINING ❑ 97.UNKNOWN 99, W j SECOA'DANY CONTAINMEM 0 I.STEEL J.FIBERGLASS OTHER $ 411a 1390.NONE 95.UNKNOWN 0 6.EMERI5OA MEMBRANE LINER ).JACKETED OV I PREVE ION 99.OTHER NS ,y} I.AUDIBLE A VISUAL ALARMSQ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF NSa "- ❑ o.TANK MEETS IiEQUIREMENTSFORE%EMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION JJz PIPING i'ONSTRUCTION ❑LSINGLE-WALLED Sl'STE\f Q99.OTHER I.PRESSURE 0 '±.GRAVITY ❑ ),CONVENTIONAL SUCTION 460 P0.IMARY CONIAINMENT 0 1.STEEL [ a.FIBERGl,A55 B.FLEXIBLE 0 J'SAFE SUCTION 23 OCR 2W J) Jsg ❑ 90.NONE [(95.UNKNOWN ❑ 99.OTNER$ 10.RIGID PLASTIC N4 6ECONUARV CONTAINMENT 0 "TEEL ( Peel%!' +baa (J J.FIBERGLASS 0 8.FLEXIBLE 10.RIGID PLASTIC ❑ 90.NONF. 0 45.UNKNOWN 099.GTHER fS iy): Nob PIPINOl1'URdINE CONTAINMENTSUMP TYPE 0 I.SINGLE WALL +Ma Vl.VENT,VAPOR RECOVERY 0 2'DOUBLE WALL 90.NONE (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 4M. l'F..NT PRihuRY CONTAINMENTU I.STEEL Ck+.FIBERGLAS$ fO.RIGID PLASTIC rET SECONDARY CONTAINMENT �•N07')E 99.OTHER(Specify) ;p,H I.STEEL +.FIBERGLASS 10,RIGID PLASTIC 90.NONE 99.OTHER(Speciy) �f VR PRIMARY CONTAINMEM' I.STEEL J.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER S N4R VR SECONDARY CONTAINMENT I.STEEL 4.FIBERGLAS$ 10.RIGID PLASTIC ( Feely) 4Na 90.NONE 99.OTHERS 1 i RISE PIPING TRANSITION SUMP iVPE I SINGI F w ( '�) 4Nh ' aISER PRHIARY COMAMMENT I I------Ci U 9U NONE N4ai _atiREiEiMDAR} - ------ ,� •..,acn��haa U IU.RIGID PLASTIC 90NONE 99ay) +61i. N) I.STEEI. J.FIBERGLASS 10,AIGID PLASTIC 90.NONE 99.OTHER(SpecNab FILL COaIPO.NENT$INSTALLED ify)I SPILL BUCKET" 7 STRIKER PLATFJBOTTOM PROTECTOR 4CONTAINMENT SUMP 464EI VII UNDER DISPENSER CONTAINMENT(UDC) 451. I CONSTRL-TION TYPE LSINGLE WALL C'ONSTRI'CTION MgTERWL 0 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE 49. I.STEEL J.FIBERGLASS 10.RIGID PLASTICI I 99._OTHER(SpaiF) VIII, CORROSION PROTECTION N9b STEEL('U�f I'ONENT PROTECTION ❑ 2.SACftIFIC1AL ANODE($) Cl 4.IMPRESSED CURRENT ❑ 6.ISOLATION JN IX. APPLICANT SIGNATURE C'ERTIPIC'.}TION: I cert!(%that tbls USl'ryrtem u cumpadble wltb the haJ+rdoua mlaabRce stored ud that tie In(ormatlpn prvrlded h;reW la true,ucurste, _ end In fuu cam Raoc;with I al t uimaleuts• `JPPLIC:1:.'I.51 N DATE /Z ' APPLIG'.N' AME(print) Jn. �2Y].I1_Sa1 by APPLICANTTITLE UPCF US 1--li- I/2 Rev.(12'3007)