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UNIFIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fO m per UST) TYPE OF ACTION (Check one item only. For an US permanent closure or removal,complete only this sedgy and Sections L II,III,IV,and IX below) 430 � 1.NEW PERMIT N 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION -6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 &UST REMOVAL DATE UST PERMANENTLY CLOSED: 4-101, DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION 1 FACILITY ID#(Agency Use Only) - - 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) BUSINESS SITE ADDRESS .iJ A�1 i ' 103(,(CITY �� 104 (�J ( H.TANK DESCRIPTION TANK ID# 2 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 435 1 �1.A STAND-ALONE TANK 1!2-ONE W A COMPARTMENTED UNIT. +,wcompift cm pow for cwh comqwbumtia�euaik DATE UST SYSTEM INST*LLED 435 TANK IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 1 437 111 TANK USE AND CONTENTS TANK USE 'pq-Ia MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING El lc AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(ocmda.Used Oil) ❑5.EMERGENCY GENERATOR FUEL.[HSC g452E1.5(c)] 419a ❑6.OTHF.RGENERATORFUE[ Q 95.UNKNOWN ❑99.OTHER( 440 CONTENTS PETROLEUM a.REGULAR UNLEADED ❑ Lc.MIDGRADE UNLEADED ❑ lb.PRE IIUMUNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS 440a ❑ 8.PETROLEUMBLE DFUEL ❑9.OTHERPETROLEUM S NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b 1L OTBERNON-PETROLEUM S IV. TANK CONSTRUCTION 443 TYPE OF TANK 1.SINGLE WALL 1&2 DOUBLE WALL ❑ 95.UNKNOWN 444 PRIMARY CONTAINMENT W1.STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444a ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN 13 99.OTHER ( 445 SECONDARY CONTAINMENT E31.STEEL ❑3.FIBERGLASS �6.EXTERIOR MBMN ANE LINER ❑7.JACKETED 4455 13 90.NONE ❑ 95.UNKNOWN ❑99 OTHER2SM2fYX. 452 OVERFILL PREVENTION E3 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE ❑ 4.TANK MEETS REQUIR]3MENTS FOR EXEMPTION FROM OVERFILLPREVENIIONEQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION 460 PIPING CONSTRUCTION ❑L SINGLE-WALLED DOUBLE-WALLED 99.OTHER SYSTEM TYPE 1.PRESSURE 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CCR 5x3) 458 PRIMARY CONTAR*AENT 1.STEN. ❑ 4 FIBERGLASS ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0 464a SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS 1399,0❑ 8.FLEXILE 1Q RIGID PLASTIC ❑90.NONE 95.I)luQVOWNTHER(S I 464c PIPINGITURBINE OONTAI IAENT SUMP TYPE1.SINGLE WALL Q 2.DOUBLE WALL 90.NONE VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specsfy) 46de 46441 VENT SECONDARY CONE 1.STEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99 OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT 1.STEEL 4.FIBBRGLASS ❑ 10.RIGID PLAmc 9o.NONE ❑99.OITHE R(Specify) 464g 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 1a RIGID PLASTIC 90.NONE ❑99.OTHER(Specify) � V` 464h1 VENT PIPING TRANSITION SUMPTYPE SINGLE 2.DOUBLE WALL 9Q NONE 464. RISER PRIMARY CONTAIIdMENT 1.ST EII WALL 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 0 99.5T1ER(Specify) 464i 1 RISER SECONDARY CONTAINMENT E3 I.STEEL 0 4.FIBERGLASS E3 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 4641c1 FILL COMPONENTS INSTALLED 1.SPII.L BUCKET .MZUCE RPLATEIBOTTOMPROTECfOR ❑4.CONTAINMENT SUMP 45ta-c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE SINGLE WALL ❑2 DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL FIBERGLASS ❑ 1Q RIGIDPLASTIC U 99.01HER ) VIII. CORROSION PROTECTION 448. STEEL COMPONEI TT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4 IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: I ceat is UST system is compatible with the hazardous substance stored and that the information provided herein 11strue,accurate, andofn full coripliance with I al uiremtmts. 470. APPLICANT SIGNA �� DATE / 4?Z APPLICANT NAME ) 471. APPLICANT TITLE Rev.(12/2007) UPCF US-B-1R ';