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i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPE TING PERMIT APPLICATION-TANK INFORMATION(olw roan UST) TYPE OF ACTION (Chock one item o ly. Form UST Perrrlallant obaum or rsnnonl,cornpkte only this ration and ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT Saliotle 1,11.Ilk N,old hebw) 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 5-CHANGE OF INFORMATION DATE US IF PERMANENTLYCLOSED S.UST REMOVAL 110i DATE EXISTING UST DISCOVERED: 1. FACILITY INFO I'ACILIT'Y fD p(Agent,✓Use Onfy) TION i BUSINESS NAME(Same as FACILIT NAME or DBA-Doing Businm As) ISu Store BUSINESSSRE ADDRESS 1 ElUsfri Ell ?Mi ye Ave 07 CITY ltatbmp a TANK ID a IL TA^/ NK DESCRIPTION I ./_'`//�� JI' TANK MANUFACTURER +)1 �TANK CONFIGURATION: TNISTANKIS v L9.1.A STANDALONE TANK }C>RXg$ ❑2.ONE IN A COMPARTMENTED UNIT. DATE UST SYS INSTALLED +3s TANK CAPACITY M GALLONS 116 Cc ee wn �,ey, _ NUMBER OF COMPARTMENTS IN THE UNIT 417 TANn u$E III.TANK USE AND CONTENTS 0 l+.MOTOR VEHICLE FU LING ❑ Ib.MARINA FUELING 03.CHEMICAL Pt 4 to T'ORAGE [J(J.HAZARDOUS WASTE IIMWe U+c4 QI) Ic.AV1AT10N FUELMG 1 ❑ 6.OTHER GENERATOR F EL 0 5.EMERGENCY GENERATOR FUEL 419 CUNI'EN"fS PETROLEUM: ❑ 93,UNKNOWN 0 99.OTHER (S i ); (HSC 6-s711'S(gl ❑ la. CULAR UNLEADED ❑ Ic.MIDORADE UNLEADED +)9+ 0 3.DI EL ,[I J.JET FUEL ❑ S5I��b,A.�PyvR1E�.M�•IU ❑ 8.p t0LEUM BLEND FUEL ¢] 9.OTHER PETROLEUM LT`___..•G NON-PETROLEUM: 7.US DOIL .W3$t,e 11 11.OTHER NON-PEI'ROLF'UM S j IU eTHANOL 119+ IV. TANK CONSTRUCTION °e1p Tl'PE UI"TANK ❑ I.SINGLE WALL Y0.111AI6Y COMAINMEM' � = UOUBLE WALL 9S.UNKNOWN ❑ STEEL ]�T]FF•L1� L3.INIBERGLASS 6.IMERNAI,BLADDEA JA 5EC0?VARY CONTAINMENT 0 7'STEEL�INTERIVAl LINIBE ❑ 95.UNKNOWN 11J 0 FIBERGLASS 6.EXTERIOR MEMBRANE OTHER IS , ), ❑ 90.NO 0 95.UNKNOWN 0 TIACKETED ,1s+ OVERFILL PREVEMION LAUDIBLE k VISUAL ALAR M$ 99.OTHER3 ); a5 2.HALL FLOAT 3.FILL TUBE SHUT-OFF VALVE +13 r-- 4.TANK MEETS KEQUIREMENFS FOR EXEMPTION FROM OVERFILL PREVEMION EQUIPMENT' I +n. V. PR011UCT/WASTE PIPING CONSTRUCTION I PIPLNG r_ON$TRUCTION 51'S31iS11l,PE ❑I.SINGLLWALLED ?.DOUBLE-WALLEU • 0 I.PRESSURE 11".OTHER YRIb1Ah{('UNTAINMENT GRAVITY 0 J. ' NVEMIONALSUCTIGN +.SAFE SUCTION .)CCR I636(sX)I IX ❑ 1.STEEL J.FIBERGLAS$ B.FLEXIBLE 0 90.NONE 95.UNKNOWN 0 99.OTHER S 10.RIGID PLASTIC SEC'O.RUARY CONTAINMEM 0 LSTEEL ( Pcetyl: +..UNKNOASSWN 8.FLEXIBLE ,N+ YIPINGi II RBI.NE CONTAINMENT SUMP TYPE NF 0 95.UNKNOWN 0 99,OTHERS city): 0 10.RIGID PLASTIC 4Mb -- )Q I.SINGLE WALLt� ul VI.VENT,VAPOR RECOVERY 0 DOUBLE WALL 90.NONE . '.'ENT YRialARY CONTAMMENT NR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464d1 I.STEEL J.FIBERGLASS 10.RIGID PLASTIC VENT SECONDARY CONTAINMEM W.NONE 99,OTHER(SpW*) I.STEEL ] J.FIBERGLASS 10.RIGID PLASTIC 464+ VR PRI!.LARY COhTA1NMEM 90.NONE 99.OTHER(SPmity) ,6'+I LSTEEL J,FIBERGLASS 10.RIGID PLASTIC 1611 VA$ECO\'UARY CONTAINMENT 90.NONE 99,OTHER($Peclty +Mn ) I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ,b i \'ENT PIPING TRANSfiION SUMP TYPE 1.SINGLE WALL OTHER(Spxity) 46/h I RISEA PRL4ARY fOMAMMEM 2.DCA ISLE WALL 90,NONE +6161 I.STEEL I I0.RIGID PLASTIC 90.NONE �` R6EA SiFC�wDAR1'CUNTAINh1ENf 99.OTHER(9, ify) I.STEEL +.FIBEKGLASS 10.RIGID PLASTIC 161 FILL COiIPVNEMSINSTALLED 90.NONE 99.OTHER(Spccity) 1:SPILL BUCK[T 3.STRIKER PLATFIBOTTOM 161+ PROTECTOR 4.CONTAINMENT SUMP CUNSTR!ACu VII• UNDER DISPENSER CONTAINMENT(UDC) 31" 1 TION TYPE l.r CO.NSTR('C'FION MATERIAL L SINGLE WgLL ❑ Vibr2.DOUBLE WALL ❑ 1.STEEL +.FIBERGLASS 10.RIGID P ❑ . ( i ES SkS 90.'NONE Uri LASTIC 99OTHER VIII. CORROSION PROTECTION 161 STEFL t':_N aONENT PROTECTION 0 ),SACRIFICIALANODI:T$) 0 4.IMPRESSED CURRENT 0 6.ISOLATION Ix. APPLICANT SIGNATURE CERTIFICnTION: I cenlfy Was tbb U$T sysrom Is compatible wIW the hazardous substance«ortd and that the Infnrnlatlon provided III Is true,accurate, and In fuH Com Bance wlth 1 sl re uln menti, ;�IPIL (IC+\^ A I UREDATE ICAY, NAME(prinQ 971 KeY1rL_Se_1hV APPLICANT'T'ITLE Z, , +s. L'PCF U'Sl'-11•I/2 '� � Rev.(IL2007)