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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an US ermanent closure or removal,complete only this section and Sections I,1I,III,IV,and DC below) 430 1.NEW PERMIT RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILIT NAME D A Dq g Busigess As) 3 BUSINESS SITE A11D, SS - 11 CI'T'Y � 104 57 MAd (( II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ❑1.A STAND-ALONE TANK S [WONE IN A COMPARTMENTED UNIT. Complete one page for each compartmmt in the unit. DATE UST SYSTEM INSTALLED 435 T CAP j�T IN GALLONS 436 NUMBER OF C ARTMENTS IN THE UNIT 437 OAZ III.fANK USE AND CONTENTS TANK USE �la MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ 1c.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bid dcs Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ In.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 W3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL XL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL EjO.FIBERGLASS ❑6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL (mss.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑2.BALL FLOAT �E 3.FELL TUBE SHUT-OFF VALVE 452- ❑ 4.TANKMEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED W DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 5LJ.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 OCR§2636(1)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL &L4.FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 464 El90.NONE 95.UNKNOWN ❑ 99.OTHER(Sp.*): 464a SECONDARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfTURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El90.NONE [199.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL (L4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464g] VR SECONDARY CONTAINMENT ❑ 1.STEEL Op.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 4h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL E16.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT �L 1.STEEL ❑4.FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464i 464il RISER SECONDARY CONTAINMENT ❑ 1.STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED NELSPILLBUCKET 3.STRDCERPLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL %2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL & 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 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 complihnce with legal requirements. APPLICANT SIGNATURE DATE azo. r0 APPLICANT NAME rin 471' APPLICANT TITLE 472' Aoj UPCF UST-13-1/2 Rev.(12/2007)