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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one formperUST) TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal, complete only this section and SectioI, 1I, III, IV, and IX below) 430 1. NEW PERMIT --N 1.RENEWAL PERMIT [15. CHANGE OnsF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 4300 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1 BUSINESS NAME (Same as FACILITY NAME or A -Doing Business As) 3 BUSINESS STT' ADDRESS• 103 CITY 104 t II. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑ 1. A STAND-ALONF. TANK ONE RV A COMPARTMENTED UNIT. ete one a ibr each cnt in the unit DATE UST SYSTEM INSTALLED 435 TAN CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNrr 437 �urc t2n 0 ev III. TANK USE AND CONTENTS TANK USE (iI a_ MOTOR VEHICLE FUELING ❑ I b. MARINA FUELING ❑ 1c:. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (In,lude Uaed oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §2528i.5(e)) ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ ]a_ REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED Wb. PREMIUM UNLEADED 440 ❑ 3. DIESEL [I5. JET FUEL [16. AVIATION GAS ❑ R. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S Leif : 440a NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11.OTHERNON-PETROLEUM. (Specify): 4406 TV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL W2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL a 3. FIBERGLASS ❑ & INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL 59. FIBERGLASS [16. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER (S i ): 4450 OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT ESC3. FILL TUBE SHUT-OFF VALVE 452 ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION [11. SINGLE -WALLED V2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE J9 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION [14. SAFE SUCTION [73 OCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ ]. STEEL W4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL qC4. FIBERGLASS [18. FLEXIBLE ❑ 10. RIGIDPLASTIC 4646 ❑ 90. NONE 95. UNKNOWN ❑ 99. OTHER (Specify): 464e PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I . STEEL jR 4. FIBERGLASS ❑ l0. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ 1. STEEL l$,4. FIBERGLASS ❑ I0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER. (Specify) 464r 4 f VR PRIMARY CONTAINMENT ❑ 1. STEEL F 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4646 464.1 VR SECONDARY CONTAINMENT ❑ L. STEEL jX4. FIBERGLASS ❑ 1 O. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 46461 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL DOUBLE WALL ❑ 90. NONE 4641 RISER PRIMARY CONTAINMENT STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Spccify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1 _ STEEL FL4. FIBERGLASS ❑ I O. RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k PILL COMPONENTS INSTALLEDL SPILL BUCKET 3. STRIKER PLATFIBOTTOM PROTECTOR 4. CONTAINMENT SUMP 4510 c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL UL2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90_ NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL WC4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b- #111. CORROSION PROTECTION STEEL COMPONENTPROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify 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 SIG RE DATE 470. S APPLICANT NA rin • , 471' APPLICANT TITLE 472. UPCF UST -B -1/2 Rev. (12/2007)