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i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form p GUST) a30* �✓ TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section CHANand GE OF INFIO.IV,and Wbegvl N ?p1� 1.NEW PERMIT ® 3.RENEWAL PERMIT 8.UST REMOVAL 6.TEMPORARY UST CLOSURE 7.USI PERMANENT CLOS URI ON SITE aaob DATE UST PERMANENTLY CLOSED; 4302 DATE EXISTING UST DISCOVERED. L FACILITY INFORMATION 1 FACILITY ID#(Agency Use ONIy) BUSINESS NAME(Same as FA01,11 Y NAME or uaP-Doing buajnesa�AS) C 104 BUSINESS SITE ADDRESS 103 CITY `f�T�[� ff.TANK DESCRIPTION TANK Tp# 43' TANK MANUFACTURER 433 #KCONFTrURA-noN: THIS TANK tS 4341.A STAND-ALONE TANK 2.ONE IN.A COMPARTMENTED UNIT, Cam Ittt one page for each com p artment in the unit DATE UST SY TEM INSTALLED 435 TANK CAPACITY l { `A1,J,4L�� 436 NUMBER OF COMPARTMENTS IN T'HE U. fr "' III.TANK USE AND CONTENTS TgNK USE � lo.MGTQR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUeLINO 437 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE nr.dudm Used OiI) ❑ 5.EMERGENCY GPNERATO FUEL[HSC y25281.5(01 4399 ❑ 6OTHFR GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99-OTHER (Specify): 440 r7!=04;=:L! GULAR UNLEADED ® Sc. 1DURADE UNLEAJ7ED $❑ 6b.P , MiUM TION UNLEADED SEL �] rAS 44oa TROLEUM BLEND FUEL ❑ 9-OTHER PETROLEUM S ciN - , ED OIL 10.ETHANOL j uob Lj 11.01-HERNON-PETROLEUM S eci IV. TANK CONSTRUCTION 443 TYPE OF TANK I.SINGLE WALL ❑ 2.DOLMLE WALL. ❑ 97.UNKNOWN j 444 PRIMARY CONTAINMENT Lj 1.STEEL 3.FTB` RGLASS ❑ 6.INTERNAL BLADDER arae ❑ 7.STEEL+INTERNA,LINING 95.UNKNOWN ❑ ".OTHER' (Specify): 4as SECONDARY CONTAINMENT ❑ 1.STEL•L ❑3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER. ❑ 7.JACYETED 95.UNKNOWN ❑99.OTHER S Cci. 4458 ❑ 90.NONE Q 452. OVERFILL PREVENTION 1.AUDIBLE&4.TANK vtEFTSIREQ IREN4SUAL AL �TS FOR EXEMPT OLL FLOAT LVE FROM OVERFILL PREVENTION E U MENT V. PRODUCT/WASTE PITTING CONSTRUCTIO 469 PIPING CONSTRUCTION I SINGLE-WALLED ❑2.DOUBLGWALLED ❑99.OTHER SYSTEM TYPEI I.PRESSURE Li2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CR 426M(a)(3) 164 L PRIMARY CONTAINMENT ❑ 1.STLEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE 10.RIGID PLASTIC a64a ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speci : 464b SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBER 3LA55 ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464e EI 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHFP(Speci : 464d PIPINGITURSINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL El 2.DOUBLE WALL 9D.NONE Vi.VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCT ON 464t VENT PRIMARY CONTAINMENT ❑ I.STEEL 4.FIHERGLA55 ❑ t0.R10ID PLAST(C 90.NONE. 99.OTHER(S ecify) 464 91 a64C VENT S1 CONAARY CONTAINMENT E] 1.STEEL [14.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER( eaifY) 464n d64S VR PRIMARY CONTAINMENT I.STELL ❑ 4.FIBERGI A55 l0.R1oID PLASTIC ❑ 90.NON£ ❑ 97.OTHER(S eoiry) 464l 464b VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS 10.R101D PLASTIC ❑ 90.NONE [] 99.OTHER( eaify) 46-1h1 ?-DOUBLE WALL 90.NONE 464i. VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 46aj RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ d.FIBERGLASS 10.RIGID PLASTIC Q 90. 111:11E 49.OTHER( ecify) 464i1 464E RISER SECONDARY CONTg1NMENT I.STEEL d.FIBERGLASS ❑ 10.R1aID PLASTIC 90.NON& 99.OTHER( eci fy) 4601 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3,STRIKE RPLATE/gOTTOM PROTECTOR ❑ 14.CONTAINMENT SU P 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) 469e CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.Nb DISPENSERS ❑. 90.NONE 469b,'9, CONSTRUCTION MATERt.pL 1.STEEL 4,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTI IER(S cify) VIII. CORROSION PROTECTION 448' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [1 4.IMPRESSED CURRENT ❑ 6.ISOLATION QC. APPLICANT SIGNATURE CLRTIFICATION: I certify that this UST system is Compatible with the hazardous substance stored and that the Information prorvil Icd herein is true,accurate, and in full jumplianc c w;tb le al re uiremenU. 170. �( DATE APPLICANT SIGNATURE �Q l/\ a7) art. APPLICANT NAME(print) AIAIS APPLICANT TITLE Rev.(12/2007) UPCF UST-B-112