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PROGRAM CONSOLIDATED FOlW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) TYPE OF ACTION (Check ow item only. For�ST pamsnmt e'0'-ar removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b FACILITY ID#(Agency Use ) 1' BUSINESS NAME(Same as FACILITY NAME or DBA Doing Business As) 3 BUS O 3 ADD, /r�//1I 103 � . _II.TANKDES�RIPTIQN. .: ;. - - TANK®# 432 TANK MANUFACTURER 433 AMCTAM IS 434 SAY/Ae JRss nAW = ❑2.ONE INA compAR11mmmm UNT. one �raaek inanndt DATE UST YSTEM INSTALLED 435 TANK CAPITACY IN ALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 431 S �pOOQ 2- TANK TANK USE grl&MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE Omk dm<UmmlOil) ❑ S.EMERGENCY GENERATOR FUELt (HSC 42sse.s(cf1 ❑6.OTHERGENERATORFUEL E3 95.UNKNOWN ❑99.OTHER( 439a CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ la hIIDGRADE UNLEADED ID�tIK PREMIUM UNLEADED 440 011.DIESEL ❑S.JET FUEL ❑6.AVIATION GAS ❑8 PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM 44% NON-PETROLEUM: 7.USED OIL 10.ETHANOL 11.OTHER NON-PETROLEUMS 440b. TYPE OF TANK 1.SINGLE WALL2 UBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 3.FIBERGLASS 0 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL G 95.UNKNOWN 99.OTHER S 444m SECONDARY CONTAINMENT 1.STEEL FIBERGLASS &EXTERIOR MEMBRANE LINER 7.JACKETED 445 NONE 13 95.UNKNOWN El 99.OTHER445a OVERFILL PREVENTION 1.AUDIBLE dt VISUAL ALARMS 2.BALL FLO •AT 3.FILL TUBE SHUT-OFF VALVE 452 Cl 4.TANK MEETS REQUIREMENTS FOR M[EMP ION FROM OVERFILL PREVENTION U[PMENT PIPING CONSTRUCTION L3 1.SINGLE-WALLED arl DOUBLE-WALLED 0 99:OTHER 460 SYSTEM TYPE PRESSURE g 2.-GRAVITY L5 I CONVENTIONAL L-uc-n-ON-M 4.SAFE SUCTION CCR§2636(,)(3)] ass PALMARY CONTAINMENT r7l 1.STEEL EV4.FIBERGLASS Q&FLEXIBLE 10.RIGID PLASTIC 464 ❑90.NONE ❑? UNKNOWN ❑99. ): 464a SECONDARY CONTAINMENT 0 L STEEL Er4.FIBERGLASS 8.FLEXIBLE 0 10.RIGID PLASTIC 464b ❑90.NONE ❑95.UNKNOWN ❑ ( ): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE'WALL Gr2.DOUBLE WALL 90.NONE 4644 -7-777777 VENT PRIMARY CONTAINMENT 0 1.STEEL .FIBERGLASS 13 10.RIGID PLASTIC Ll 90.NONE U99.OIm(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT C3 1.STEEL 4 ERGLA34 13 10.RIGIDPLASTIC 90.NONE El 99.OTHER(Specify) 464f 4648 VR PRIMARY CONTAINMENT 13 1.STEEL 4. GLASS 13 10.RIGID PLASTIC 0 90.NONE E3 99 OTHER(Specify) 464E VR SECONDARY CONTAINMENT El 1.STEEL U 4.FIBERGLASS 1110.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464b 464ht VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 L0.RIGIDPLASTIC U 90.NONE U ".OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT E3 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE El 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED GrI.SPILLBUCKET CKSTRIJUMPLATEMOTTOMPROTECTOR 4.CONTAINMENT SUMP 451" CONSTRUCTION TYPE ❑ 1.SINGLE WAIL 2.DOUBLE WALL ❑3.NO DISPENSERS -Cl 90.NONE 46% CONSTRUCTION MATERIAL 1.STEEL. FIBEROLASS El 10.RIGIDPLASTIC 1399.OTEER 469bc r VIIIABRRSigP " IION STEEL.COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.RM1PRESSED CURRENT ❑ 6.ISOLATION 44& jDt0000ATF7RE CERTIFICATION:I certify that this UST system Is compatible with the hazardous substance stared and that the Informadon provided herein Is true,accurate, mW in ftl eamoviloney with lead regulmenwats. APPLICANT SIGNATURE DATE 2G'� c, a� APPLICANT NAME(print) 471. APPLICANT TITLE Loci a1z. UPCF UST-B-1/2 Rev.(1=07)