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Q <br /> aft At- <br /> i IED PROGRAM CONSOLIDATED FO. <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form p:ST) <br /> Iy f <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 411,X..1V and!X beloly) <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ &TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE [18.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4301. 1 DATE EXISTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ �_ 1_ <br /> BU. E(Same as Facility rVame or DBA-Doing Business.4s) 3 <br /> h ll/T o <br /> ESS SITE ADDRESS 103. 1 CITY 104 <br /> 13975 E. Hiway 88 Lockeford <br /> H. TANK DESCRIPTION <br /> TANK ID# j 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434, <br /> x,220 STIP M L A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT companment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 1990 10,000 1 <br /> III. TANK USE AND CONTENTS <br /> TANK USE M la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ IC. <br /> AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(.)] <br /> _❑ 6.OTHER GENERATOR FUEL ❑ 95,UNKNOWN ____ 1199.OTHER( P fyY S eci 439a <br /> _ <br /> CONTENTS PETROLEUM: M Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ^❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> - _ ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4401 <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL - <br /> ❑ 11.OTHER NON-PETROLEUM(S eci •): 4406, <br /> IV. TANK CONSTRUCTION <br /> _TYPE OF TANK ❑ 1.SINGLE WALL M 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT M 1.STEEL ❑ 3.FIBERGLASS` ❑ 6.INTERNAL BLADDER- v - 444 <br /> _ _0 7 STEEL+INTERNAL LINING _ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. <br /> SECONDARY CONTAINMENT 0 1.STEEL -� ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER M 7.JACKETED 44s. <br /> ____ [I90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT -�M 3.FILL TUBE SHUT-OFF VALVE 452 <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION -_❑ 1.SINGLE WALL M 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE �® L PRESSURE !❑ 2.GRAVITY ❑ 3.CONVENTIONAL_SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(_3)1 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN _❑_99.OTHER(Specif_y):_ 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 3.FLEXIBLE- ❑ 10.RIGID PLASTIC 4616 <br /> ❑ 90.NONE ❑ 95.UNKNOWN_ ❑ 99.OTHER(Specify): 464c. <br /> PIPINGf-fURBINE CONTAINMENf SUMP TYPE M 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. <br /> VI. VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT M 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify): 464e <br /> _ 464e1. <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC M 90.NONE ❑ 99.OTHER(Specify): 6464( <br /> ---- --- -_ _ 464n4n <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464g. <br /> �__.. -- ---- 46481- <br /> VR SECONDARY CONTAINMENT -❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC M 90.NONE ❑ 99.OTHER(Specify): �hh <br /> VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL_ M 90.NONE 464' <br /> RISER PRIMARY CONTAINMENT M 1.STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 464). <br /> '---- -__.-- 464i1. <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC_ M 90.NONE ❑ 99.OTHER(Specify): 464k. <br /> _ 4641 <br /> FILL COMPONENTS INSTALLED M I.SPILL BUCKET M 3.STRIKER PLATEIBOTFOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4511-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE M 1.SINGLE WALL - _ ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑_ 90.NONE 469a. <br /> CONSTRUCTION MATERIAL M 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) _- 4696' <br /> 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION M 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 443. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE c. DATE 12/1/2010 A70 <br /> APPLICANT NAME(print) Sandy Ed ardS 471 APPLICANT TITLE Environmental Compliance 472 <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />