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a Am UNIFIED PROGRAM CONSOLIDATED FORML UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) OF ACTION (Check one item only. For an UST permanent closure m removal,complete only this section � and Sections L II,III,IV,and IX below) 430 ,r-I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 4306 FACILITY ID#(Agency Use Only) -L FACILITY INFORMATION - 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) I 3 Mt� BUSINESS SITE ADDRESS o _ 103 CITY 104 (/ II.TANK DESCRIPTION TANK)D t1 32 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 43a ' 7 �� A E NA ALONE TANK i,/� MftW 2.ONE IN A COMPARTMEtaTED UNIT. aae 1'are9. tin Poe mut DATE UST SYSTEM INSTALLED 435 TANK CAPA IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 HL TANK USE AND CONTENTS TANK USE MOTOR VEHICLE FUELING El lb.MARINA FUELING ❑ I c.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hwhkles Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC P5281.5(o)j ❑6.0THER GENERATOR FUEL 95.UNKNOWN ❑99.OTHER(Specify)._ 44 a40 0 CONTENTS PETROLEUM: [3 la REGULAR UNLEADED ❑ lc.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 4 J1.3.DIESEL ❑5.JET FUEL ❑6.AVIATION GAS .PETROLEUMBLE DFUEL ❑ 9.OTHER PETROLEUM S . a4oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 440b II.OTHER NON-PETROLEUM S IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL JL1 DOUBLE WALL U 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 13 7.STfifiC+INTERNAL LINING Q 95.UNKNOWN 13 99.OTHER ( ): 4449 SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS W6.EXTERIOR MEMBRANE LINER ❑ 7.JACKEM 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3 FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUMEME NTS FOR EXEMPTION FROM OVERFILL ON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED U2.DOUBLE-WAL IM) E3 99 OTHER � SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY 3.CONVENTIONAL SUCTION a 4.SAFE SUCTION 23_CCR§2 3 ass PRIMARY CONTADIMI NT El1.STEM ❑ 4.FIBERGLASS 138.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ NE ❑90.NO95.UNKNOWN 1399.OTHER( i : 4649 SECONDARY CONTAINMENT ❑ 1.STEELFIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90 NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ): 4640 PIPING/TURBIINE CONTAR*AENT SUMP TYPE Wrt,SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT U I.STEEL 4.FIBERGLASS u 10.RIGID PLASTIC 13 90.NONE 0 99 OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 0 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4641' 4641 VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Specify) 4648 -464S1 VR SECONDARY CONTAINMENT ❑ 1. .FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) abs 46441 VENT PIPING TRANSITION SUMP TYPfi 1.SINGLE WALL 2.DOUBLE WALL V 90.NONE 4". RISERPRIMARY CONTAINMENT .STEEL. 4.FFIBERGLASSU 10.RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 464) I RISER SECONDARY CONTAINMENT STEEL '-[3 1. 4.-FIBERGLASS FIBERGLASS .10.RIGID PLASTIC NONE 99-OTHER(Specify) 4641 46411 FILL COMPONENTS INSTALLED ILL BUCKET PLATEIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 4519-c VII.UNDER L§PENSER CONTAINMENT(UDC) CONSTRUCTION TYPE i.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPIINSERS ❑90.NONE 4699 CONSTRUCTION MATERIAL ❑ .S EEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 99.01MIK(bPeCHY) VIM CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION- I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein.is ttu;.accurate, and in full4ompliance with legal r u' ents. 470. APPLICANT SIGNATURE DATE 471. APPLICANT 'i a72 T TITLE APPLICANT NAME ) v Rev.(12/2W7)UPCF UST-B-1/2