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r UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION one form UST) TYPE OF ACTION. (Check one item only. For an UST petmanent closure or removal,completeonly this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a3o9 DATE EXISTING UST DISCOVERED: 430b L FACT .I'I'Y INFii;MTON , FACILITY ID#?A_ja cy Uae Only) i BUSINE NAME(Saine as FACILITY NAME or DBA-Doing Business As) 3 .cam' BUS SSUrE ADDRESSA aG+[T 1 oc�Co to Ar�' 1!T `DF.�CRIPTIO` IST. TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THLS TANK IS 434 I A STAND-ALONE TANK ONE IN A COMPARTMENTED UNIT. cJ�-�.�� oas tioravoh in wit DATET SY 435 TANK CAPACITY 8 LONS 436 NUMBER OF COMPAJtTMENTS IN THE UNIT 4n •• 1 7777777 `fIt'0*0* LVD Cf/i�l'I' TS TANK USE Is.MOTOR Vf:aE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑3.CHF1111CAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(bwhWw Ured 00) ❑ 5.EMERGENCY GENERATOR FUEL[mc 12328 i.s(c)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Sp%*): 439a CONTENTS PETROLEUM: ❑ IS.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED IX Ib.PREMIUM UNLEADED 490 [13.DIESEL ❑5.JET FUEL 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440' NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL 1 1.OTHER NON-PETROLEUM 440» TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL 9S.UNKNOWN 443 PRIMARY CONTAINMENT STEEL 3.FIBERGLASS 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑95.UNKNOWN [199.OTHER S 4449 SECONDARY CONTAINMENT L MELn3ft6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 . 90.NONE .UNKNOWN 13 99.OTHER(spew, 4459 OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL.PREVENTION$ UIPMENT w, PROD�L"i`�V[�`A�EPII�C CON►'�' I��TIQ�1' ;;;, PIPING CONSTRUCTION 1.SINGLE-WALLED DOUBLE.WALIRD 13 99.OTHER 460 SYSTEM TYPE .PRESSURE 2.GRAVITY Q 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION 3 CCR 263 a 3 458 PRIMARY CONTAINMENT Ej 1.STEEL PL4.FIBERGLASS El S.FLEXIBLE 0 10.RIGID PLASTIC 464 ❑ 90.NONE Q 95.UNKNOWN ❑ 99.0 Specily): 4649 SECONDARY CONTAINMENT 0 1.STEEL Nr4.FIBERGLASS U S.FLEXIBLE 0 10.RIGID PLASTIC 464b ❑90.NONE ❑ 9S.UNKNOWN 99.OTHER(Specift 4649 PIPINGn`URBINB CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464d �: VI:V :1�1`I'4'4 AI ;YIt "CO A►1 � •IxPIIfE;P 'INfT: ' 11T7`RUC1'I ►N VENT PRIMARY CONTAINMENT 1.STEEL JL 4.FIBERGLASS E3 10.RIGID PLASTIC E3 90.NONE 0 99.OTHER(Specify) 4649 464el VENT SECONDARY CONTAINMENT 1.STEEL .FIBERGLASS 13 10.RIGID PLASTIC W 90.NONE 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT XI.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 9o.NONE 13 99.OTHER(Specify) 464, 464gl VR SECONDARY CONTAINMENT E3 1.STEEL 13 4.FIBERGLASS DtiO.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 64ht VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL 4 90.NONE 4641. RISER PRIMARY CONTAINMENT WJ1.STEEL U 4.FIBERGLASS U 10.RIGIDPLASTIC U 90.NONE. 099.OTHER(Spedly) 464) 4640 RISER SECONDARY CONTAINMENT 1.STEEL E3 4.FIBERGLASS Mo.RLGID PLASTIC 90.NONE 94.OTHER(Specify) 464k FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRBC$R PIAT F1B01'fOM PROTECTOR 4. 464ki ONTAINM$NT SUMP 4519•c ' 'DIY:ITR`DiIRPENSER C(! �, �NT:�, CONSTRUCTION TYPE I.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 4699 CONSTRUCTION MATERL4L 1.STEELC1 4.FIBERGLASS 10.RKLID PLASTIC99.OTHER 469bc STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ALODE(3) ❑4.IMPRESSED CURRENT 6.ISOLATION 448. III:. a4MU- 1NI".5 ( T�1TUl ' . .... CERTIFICATION:I cerftpq this UST system is comp uffile wRim too 6san teas saw stortd sad fist the iatarmatlea ptmdded-64srela Is taus,accurate, sad 1a wlt6 a1 a . APPLICANT SIGNATURE 1 DATE 470. APPLICANT NAME(print) j 471. 1APPLICANT TITLE r.°`' 472. UPCF UST-B-1/2 Rev.(12/2007}