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UNIFIED PROGRAi4l CONSOLIDATED FORmNI UNDERGROUND STORAGE TANK OPERATING PERMIT,APPLICATION-TANK INI+ORMA' ION(One form per ST) TYPE OF ACTION (Check one item only. Foran UST permanent closute or removal,complete only(his section and Sections 1.H.Ill.IV.and]) below) 4;Q E] 1.NEW PERMIT ® 3.RE.5 AL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PER.MANEN'C CLO SURE ON SITE El S.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I. FACILITY WNI!ORMATION FACILITY iD r(Agency We 010 BUSINESS NAME(Same as FACILI'l iNAME of OQA-Doing business As) BUSINESS SITE ADDRESS 10' CITY 1Oi II.TANK DESCRIPTION TANK ID 491 32 TANK MANUFACTURER -i3 TANKCONFIGURaTION: THIS T.ANt�15 XI.A STAND-.ALOI:ETAN•t1 2.ONE rNA CONIPAPTNIP-'ZTED L'NCr. tom ler One for each coin&RiMm In lh . DATE UST 5 x_ c.vi INSTALLED 4;9 TAMC AsjT IN GALLONS 4;6 NUivIBVR OF COMPARTMENTS IT THE UNI +37 111.TANK USE AND CONTENTS ! TANK USE I a.MOTOR VEHICLE FUELING a Ib.MARINA FUELING ❑ Ic.T�[.AION FUELING 4;9 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS AVASTE()nrjud--steed Oil) Q = EMIERCiENCZ'GENERATOR F 1£L 1Hse(-'t'BI.3(G( 4301[I G.OTHER GENERATOR FL•EL (295.CNKNOAA� ❑ 99.OTHER (S edfvi: CONTEN'T'S PETROLEUM: J9 I4.REGULAR L'NLE.ADED N Ic.MIDGRADE UNLEADED M 1UMI UNLEADED JJQ O 3.DIESEL ❑ S.JET FUEL ❑ 6.AA'IATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM ($ cifO: i 4o0a NON-PETROLEUIV,:❑ 7,USED OIL Li10.ETHA.\ 440b ❑ 11.OTHER NON-PETROLEU:vI(S ecit'): IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 3.DOUBLE WALT. ❑ 95.L°NKNO\A1 '143 PRIMARY CONTAINMENT Lj 1.STEEL 1&3.FIBERGLASS [16.TNTER.NAL BLADDER 444 ❑ 7.STEEL-INTERNAL LINING El 95.UNKNOAt'X ❑ 99.OTHF,R (S ecifr): Ja e SECONDARY CONTANMIiNT ❑ 1.STEEL ❑3.FIBERGLASS 6.EITERIOR NIbMBRa;E LINER ❑ 7.JAC>;LTED 4456 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Spetifj•): 0MERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE$HUT•OFF VALVE I`2 4.TANK MEETS REQUIRENmE;NTS FOR EXEMPTION FROM OVERFILL PREVENTION EQGIPMIENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.SINGLE tYALLED ❑2.DOUBLE-WALLED ❑99.OTHER J60 SYSTEM TYPE, ❑ 1.PRESSURE ❑ 2•GRAVITY ❑ 3.CONA'E\'T[OXAL SUCTION ❑ 4!SAFE SUCTION[23 CC] §§2636(a)(3)1 s+)1 PRIMARY CONTAINMENT [1ElI.STEEL 4.FIBERGLASS S.FLUXIBLE ❑ 10.R4M IGID PLASTIC J4(4 El 90.\ONE ❑ 97.UNKNOWN [] 99.OTHER(S ocifr): SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLrEXIBLE ❑ 10.RIGID PLASTIC 46�b ❑ 90.NONE ❑ 95.UNKNOWN C199.OTHER(S ecif�v): 46 PIPING,TUR131NE CONTAINIMENTSUMP TYPE Q 1.SINGLE A7,xI.L ❑ Z.DOUBLE AA'ALL ❑ 90.NONE •644 d VT.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTIO VENT PKIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ )0,RIGID PLASTIC ff 90.\OKE ❑ 99.OTHER(Spec ) 4 VENT SECONDARYE CON7AINMENT ❑ 1.STEL -t.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spec 4641 s6<fl VR PRIMARY CONTA1NME;NT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC90.NONE ❑ 99.OTHER(Spec :) 16rY 46.1 VR SECONDARY CONTAINNIENT m.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(S Pee ) abrn 464nm VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE W ALL 3.DOU91-F.WALL 90.\O\E 464i. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RtGlp PLASTIC 90.\ONE 99.OTHER{Sp ry) 4Wi 4oJ 1 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.0?HLR(Spec .) 154 RISER SECONDARY CON7AINMIENT 1.STEEL ❑ 4G4k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRKER PLATE BOTTOMI PROTECTOR ❑ 4. MI:� E\Aml:\T SUMP x5�a c VII.U;\'DER DISPENSER COiiNTAI\*MINT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE`HALL ff 2.DOUBLE WALL ❑ 3.NO D PENSERS ❑ 90 NONE 4690 CONSTRUCTION h•EATERIAL 0 I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(S -i ) 46%-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT C] 6.ISOLATION 4JB, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the bazardous substance stored and that the information provided herein is true,accurate, and in ful! m liance with Imeal requirements. ! � APPLICANT SIGNATURE 470. / DATE -- �s L;. ��j 17; m _ 472 ' APPLICANT NAME(print) ; ? APPLICANT TITLE UPCF UST-B-1/2 Rev'.(12/2007)