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�i �FIED PROGRAM CONSOLIDATED FOI UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) I�C4f lI TYPE OF ACTION (Check one item only Far a US)'closure or removal,romplete only this section and Sections 111. 111 1V.and!Y below) ❑ L NEW PERMIT +30 ❑ 3.RENEWAL PERMIT S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE8.UST REMOVAL DATE UST PERMANENTLY CLOSED: U(V DATE EXISTSTING UDISCOVERED: q9e I. FACILITY INFORMATION FACILITY ID 8("gen 'Use Only) BUSINESS meas Airy Mame or DBA-Doing Business.4s) 4FUELING4'IN.'elUresoro 68150 03CITYa13975 E. Hiwa 88 LOckefordII. TANK DESCRIPTIONTANKIDN 432TANK MANUFACTURER 433 TANK CONFIGURAS 434STIP ® I.A STAND-ALONCompin.on pyc fn nraDATE UST SYSTEM INSTALLED 435 El 2.ONE IN A COMPcmpmewn in,6e uv,.TANK CAPACITY IN GALLONS a6 NUMBER OF COMPE UNIT 4371990 10,000 III. TANK USE AND CONTENTSTANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATI43.. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(5 Il um an ❑ 5,EMERGENCY GENERATOR FUEL IHsc fzuet5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99 OTHER( ft). 41% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Sjmi ): 44q. NON-PETROLEUM: 7.USED OIL 10.ETHANOL ❑ IL OTHER NON-PETROLEUMS i : 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN ____ µ3 PRIMARY CONTAINMENT 11 1.STEEL ❑ 3.FIBERGLASS E3ERNAL BLA 6.INTDDER 4M ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): 444. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED us __ _❑ 90.NONE ❑ 95.UNKNOWN ❑99 OTHER(Specify): M5. OVERFILL PREVENTION ❑ I.AUDIBLE @VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 4sz. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99 OTHER _ _ 440. SYSTEM TYPE ® LPRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR fUWj X))1 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10,RIGID PLASTIC 444 90.NONE ❑ 95.UNKNOWN 99.OTHER(S iyl' 4N. SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4445 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 441c PPINGITURBINE CONTANMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 44W VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION FERPMARYCONTAINMENT ® 1STEEL ❑ 4FIBERGLASS ❑ 10NE ❑ 99.OTHER(Specify):SECONDARYCONTAINMENT ❑ ISTEEL ❑ 4FIBERGLASS ❑ 10RIGID PLSNE ❑ 99.OTHER(Specify):IMARY CONTAINMENT ❑ 1.STEEL ® 1.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e' VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): ami VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE RISER PRIMARY CONTAINMENT 19 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 1 RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): *411 FILL COMPONENTS INSTALLED N 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 VII- UNDER DISPENSER CONTAINMENT(UDQ CONSTRUCTION TYPE _ _®_ 1 SINGLE_WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS_ ❑ 90.NONE 4� CONSTRUCTION MATERIAL ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Spee fy) ad9c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ® 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44s IX. APPLICANT SIGNATURE CERTIFICATION: I certifv 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 12/1/2010 470 APPLICANT NAME(print) Sandy Ekwards 471 APPLICANT TITLE Environmental Compliance °n UPCF LIST-B Rev.(122007)-1/3 www.RRidoes.otg