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D� fa�Z �IZ Iw v UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one loon Per UST) TYPE OF ACTION (Check one item only. For an UST pennnnent closurc or removal,complete only this section Bad Sections I,it,III,IV,and IX below) 130 ❑ !.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Lao 'TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: °Ja DATE EXISTING UST DISCOVERED: 43(b I. FACILITY INFORMATION FACILITY ID q(Agency We Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 i Super Store Industries BCSINP:SS SITE ADDRESS 103 CITY la LathrO 1l.TANK DESCRIPTION TANK IDa ^ 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 f (� !'1 I G� 2 MXES+ ®I.A STAND-ALONE TANK ✓ > ©2.ONE IN A COMPARTMENTED UNIT. DATE.UST SYSTEM INSTALLED--435 Com ea om for each. In Weed, TANK CAPACITY M GALLONS ua NUMBER OF COMPARTMENTS IN THE UNIT a] III.TANK USE AND CONTENTS TANK LSE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVLATIONFUELM 439 ! ❑ J.CHEMICAL PRODUCT STORAGE ❑ I.HAZARDOUS WASTE(Me Uu4010 S.EMERGEN RATOR 7UEELMI ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 99.OTHE (S i >:Fresh SMI a9, CON-ITE\"f3 PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ Ib.PREM 440 ❑ 3.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHERPETROLEUM S i : 41W NON-PETROLEUM:❑ ].USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM $ i : +Wb IV. TANK CONSTRUCTION n PE Ur''.'ANK ❑ LSINGLE WALL 2.DOUBLE WALL 093.UNKNOWN +J3 YRIb1Alt1'CONTAINMENT ❑ 1.STEEL J.FIBERGLASS ❑ 6.HlfERN.L BLADDER ++J C3 ].STEEL�INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,pTHER 5 i ): u4. SECON; YCONTAINMENT ❑ I.STEEL �l].FIBERGLASS ❑ 6.EXTERIOR MEMBRANELIER _ ].JACKETED HS ❑ 90.NONE [) 95.UNKNOWN ❑99.OTHER(S i ); eay OVERFIL:.PREVENTION I.AUDIBLE&VISUALALARMS U 2.BALL FLOAT ).FILL TUBE SHUT-OFF VALVE +R. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT I V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLEWALLED 2.DOUBLE-WALLED ❑99.pTHER 160 SI'STF,.N!1"•.'PE ❑ LPRESSURE ?.GRAVITY J.CONVENTIONALSUCTION ❑ LSAFE SUCTION ¢)CCR 26JNaXJ) 458 PRUTAk'i CON I INNIENI ❑ I.STEEL ) f 4,FIBERGLASS 8.FLEXIBLE 10.RIGID PLASTIC 464 O 90.NONE ] 95,UNKNOWN ❑ 99.OTHER(Specify): a6 SECOU31i1Y CONTAINMENT ❑ I.STEEL ff] 4.FIBERGLASS ❑ S.FLEXIBLE 10.RIGID PLASTIC 464b ❑ 90.NONEa 95.UNKNOWN ❑ 99.OTHER(Specify): PIPING!IY?BIN'E CONAINMENT SUMP TYPELJ I.SINGLE WALL U 2.DOUBLE WALL 90.NONE 46M VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPQN CONSTRUCTION ENT PKIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RiulurIASTIC W.NONE 99.OTHER(Speciy) 4Me JEST SECIiNDA0.Y GGNAINMEN LSTEEL J.FIBERGLASS 10.RI GID PLASTIC 90.NONE 99.OTHER(Speciy) 4641 I VR PRINI AR Y CON I'AINMEN I.STEEL 4.FIBERGLASS Io.RIGID PLASTIC 90.NONE 99.OTHER ISpeciy) �a 46 5'R SECUNDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHERS (Specify) 4Mh l'ENT P I.'ISG TRANSIT ION SUMP TYPE 1.SINGLE WALL 4Mh1 2.DOUBLE WALL 90.NONE 46gi RISER PRU L4RY CONAMMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(Spe<iy) +Mj RISER SEiuN'DARY CONTAINhiENU 1.STEEL 04 4.FIBERGLASS U 10.RIGID PLASTIC U W.NONE 99.OTHER(Specify) 44Nh FILL CO>!Pu.NENS INSTALLED I.SPILL BUCKET i6ik1 J.STftIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP Olwc VII.UNDER DISPENSER CONTAINMENT(UDC) COSSTR LC NON TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ ),NO DISPENSERS l3 90.NONE 169. CO.N'STRI'C'f10N MATERIAL ❑ I.STEEL I.FIBERGLASS CK 10.RIGID PLASTIC 99.OTHER(S i ) 469bs VIII. CORROSION PROTECTION ElEEL C.,N!:'O4E;YI PROTECTION ❑ 2,SACRIFICIAL ANODI''(S) rI 4.IMPRESSED CURRENT 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system le comp,,ible with the huardoussubsrance stored and that the information provided herein is We,accurate, and la fuUu compliance with]!Sal re uimments. ' APPLIC.+.N. S TRE DATE oa. = APPLIC Xi NAME(print) 4]I' APPLICANT TITLE 4n. _ Kevin Selby Facility Manager/Operations Mgr. LPCF US I%It- 112 Rev.(II/2007)