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UNEFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION One form Pe,usT) TYPE OF ACTION (Check one item only. For an UST palmanew costue or removal,compleoe only this section and Sw ion 430 131.NEW PERMIT 13 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION helaw) El ti.TEl1oRARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED; DATE EXISTING UST DISCOVERED: utb J. Iii N FACB:TfY ID#(Agency Use ,) I I BUSINESS NAME(Samo as FACILITY NAME or DBA Doing Budoae As) w cff- N 5G- BUSINESS SITE ADDRESS CITY t Mol �7d d ,�T 04 TANK ID# 432 TANKMANUFACIU + TAN[CONPIOURA7tOl4 TELS TANK 15 434 ❑1.A srANo-AzoNErANK 2.ONEI4A�ARTIENTEDUNiT. oee fort.nowt. DATE UST SYSTEM INSTALLED 43s TANK ACtTY IN GALLONS 436 NUMBER OF COMPARTMEN3 IN THE UNIT � TANK USE Mk ,.Is,MGM VEHICLE FUELING 0 ib.MARINA FUELING 0 lc.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOIB WASTE addm Wed oo) 0 S.EmERG@iCY GENBRATOR FUEL pac i i.Rc)] 0 6-OTHER GENERATOR FUEL 0 95.Um Qxm 0 99.OTHER(Specs : 439a CONTENTS PETROLEUM: 19 le.REGUI AR UNLEADED M la M DORADE UNLEADED 4b.PREMIUM UNLEADED 440 0 3.DIESEL 0 S.JET FUEL 6&AVIATION GAS 0&PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM 44aa NON-PETROLEUM: 7.USED OIL E3 10.ETHANOL 11.OTHER NON-PETROLEUM 440b TYPE OF TANK U 1.SINGLE WALL 2.1 WALL .. 93.UNKNOWN 443 PRIMARY CONTAR04M 1.STEEL 3.FIBERGLASS 13 6.INTERNAL BLADDER 444 ff 7.STEEL+INTERNAL LINING 0 93.UNKNOWN 13 99.OTHER. 444e SECONDARY CONTAINMENT 1.STIHH Lj 3.FIBERGLASS Ll 6.EXTERIOR MEMBRANE LIVER W 7.JACKETED 443 90.NONE 95.UNKNOWN 99.OTHER 443e OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS E3 2.BAIL FLOAT 3.FILL TUBESHUT-OFF VALVE 43t 0 4.TANK MEETS UIREMENf3 FOR EXEMPTION FRAU OVERFILL PREVENTION U!P►!ffiV1 PI LNG CONSTRUCTION 1.SINGLE-WALLED 2.DOUBLE-WAL M 99.OTHER 46D SYSTEM TYPEi.PRESSURE 2.GRAVITY 3.CONVENTIONAL SUCTION 4.SAFE SUCTION f7Qt ) 438 PRIMARY OONTAIVAHINI 1.STEEL 4.FIBERGIASS S FLEXIBLE L3 10.RIGID PLASTIC Ota 0 90.NONE 95.UNKNOWN 0 99. ' ): 466 SECONDARY CONfAINME T! U 1.STEEL 93 4.FIBERGLASS E3&FLE)GBI.E 0 10.RIGID PLASTIC 464b 0 90.NONE 0 9S.UNKNOWN 0 99.OTTIER ): 464. PRgNGaXWJ LVE CONTAINhIOW SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4614 VffidI PRIMARY CONTAI[VMII'TI11 1.STEEL 014.FIBERGLASS U 10.RKLID PLASTIC U 90.NONE E3 99 OTHER(Specify) 4644 VENT SECONDARY CONTAINMENT 0 I.STEEL 914.FIBERGLASS 0 1&RIGID PLASTIC 90.NONE EJ 99.OTHER(Specify) 4610 VR PRIMARY CONTAn0AENt 13 1.STEEL, 4.FIBERGLASS 13 10.RIGID PLASTIC EJ 90.NONE 13 99.OTHBR(Specify) 46% VR SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 1 13 l0.RIGID PLASTIC 13 90.NONE o 99.OTHER(Specify) 46b 46M VENT PIPING TRANSITION SUMP TYPE LI I.SINGIE WALL 0 2.DOUBLE WALL 90.NONE REM PRIMARY CONTAINMENT L STEEL 0 4.FIBERGLASS U 10.RREIDPLASTIC U 90.NONE 13 99.ornm met*) 464 RISER SECONDARY CONTAINMENT E3 1.STEEL E3 4.FIBERGLASS 13 10.RKHD PLASTIC 990.NONE1399.OTHER(Specie) 464k 461tt FILL iX>MEONEIYIS LNSTAILED E.SPH.L BUCKET 3.STRBC®t PIA'l81BOT!'O!U PROTECTOR 4.CONTAINMENT SUMP 45tes Mum CONSTRUCTION TYPE1.SI4CiLE WALL 2.DOUBLE WALL 0 3.NO DIS!ffi4SER3 ❑90.NONE CONSTRUCTION MATERIAL 1.STEPL. 4.FIBERGLASS 10.RIGID PLASTIC 99. 46bc STEEL COMPONENT PROTECTION 0 2.SACRWXXAI, n.,. AIVODE(S) +0 4. CURRENT a 6.1SOLATION ,..44R 7l'D . CERTIFICATION:I eattllf fiat trh UST'systetel h eompagWe with the ioaedoar se�fasiee sfeead sad tot tie tateraaatlea lYee els h ttte,aeea�ee, mw k fee comodbumee TA& atroadtts, APPLICANT SIAE_�, -_ � Q :'", DATE I.� t ��;4�J w,�^':�1�"ab�iPJif APPLICANTNAME(pdot) rr aH - 1 APPLICANT TITLE � '� '_." . ;. , , 472. UPCF UST41-b7 Itev.pv=7)