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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Checkone item only. Fore UST closure or removal,complete ally this section and Seclions 1,IL 111,IK aad lX beloaJ 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION El 6.TEMPORARY UST CLOSURE ❑ 7.USTPERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST D)SCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) BUSINESS NAME(Same as Facility Nmne or DBA-Doing Business As) 3. V,mke 's Le # S BUSINESS SITE ADDRESS 103. CITY 104. 2/9 11�vVA4 ce �.a.►� STock7_OAI II. TANK DESCRIPTION TANK IDN 'T'f{os15.� TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. T�rae /\�y ❑ I.A STAND-ALONE TANK Complete one pasefareach �S 2.ONE INA COMPARTMENTED UNIT -Pa,fteW ie a1ou01L DATE UST SYS EM INSTALLBD +33. TAMC CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS IN TIE UNIT 437 o?- Zoo O 00 wa III. TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE C.O des11ecd oil) ❑ 5.EMERGENCY GENERATOR FUEL p3SCM261.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439, CONTENTS PETROLEUM: ❑ 1a.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ lb.PRE-MIUMUNLEADED 440. X3,DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4400. NON•PETROLEUM:❑ 7.USED OIL ❑ METHANOL ❑ 11.OTHER NON-PETROLEUM(S eei ): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1,SINGLE WALL 2.DOUDLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. _ ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444%. SECONDARY CONTAINMENT ❑ 1.STEEL 1903.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 9D.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 4454 OVERFILL PREVENTION ;ff1.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT [13.FILL TUBE SHUT-OFF VALVE 4524.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL 99.OTHER 460 SYSTEM TYPE 1.PRESSURE-[1�.,2.GRAVITY _❑ 3.CONVENTIONAL SUCTION_❑_4.SA §203 _FE SUCTIONj23CcR6(a)331._,.- 459. PRIMARY CONTAINMENT ❑ I.STEEL k4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, SECONDARY CONTAINMENT ❑ I.STEEL 111'4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4W, PIPINGIfURBINE CONTAINMENT SUMP TYPE ❑ LSINGLE WALL %2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ LSTEL X44.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464aL VENT SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 464. _ _ _ ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464D VR PRIMARY CONTAINMENT ❑ 1.STEEL lit4.FIBERGLASS ❑ IO.RIGIDPLAS7IC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 ¢, VR SECONDARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS [3 10.RIGID PLASTIC E290.NONE ❑ 99.OTHER(Specify): 464111 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLEWALL 2.DOUBLE WALL ❑ 90.NONE 464'. RISER PRIMARY CONTAINMENT STEEL X4,FIBERGLASS ❑ 10,R1GIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(S eci 44'11' �.I. P E')� 4sf 1. RISER SECONDARY CONTAINMENT ❑ I.STEEL �4.FIBERGLASS ❑ 111.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 41 FILL COMPONENTS INSTALLED .SPILL BUCKET 3.STRIKER PLATER3OT70M PROTECTOR XF1.CONTAINMENT SUMP F-5 LOOP VII. UNDER DISPENSER CONTAINMENT (UDC) e s CONSTRUCTION TYPE _ ❑ 1.SINGLE WALL __JK2.DOUBLE WALL [1 3.NO DISPENSERS ❑ 90.NONE 8`,.,,,._ CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) '4 ' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT .150LA770N 44& IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible mith the hazardous substance stored and that the information provided herein 1 accurate,and in full co fiance with I al requirements. APPLICANTSIGNATURE G DATE 7-1 -09 + APPLICANT NAME(print) tA. d rt_1_f0 471APPLICANT TITLT r. r 1 1_ 472 UPCF UST-B Rev.(1212007)-12 C\ nm�w.unidocs.org ,l G{L-