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MFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> IT,YP:�11'ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 <br /> 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> 430bDATE UST PERMANENTLY CLOSED: <br /> 430aDATE EXISTING UST DISCOVERED: <br /> L FACILITY INFORMATION <br /> I <br /> FACILITY ID#(Agency Use Only) - - <br /> 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> BUSINESS SITE ADDRESS 103 f 1 CITY Mp 0.� 104 <br /> III <br /> .TANK DESCRIPTION <br /> i�.� <br /> TANK ID g 2 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> 01'A STAND-ALONE TANK <br /> I ❑1 ONE IN A COMPARTMENTED UNIT. <br /> compleft one PW for each campatow in be uut <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPA(WALLONS 436 NUMBER OF COMPART ENTS IN THE UNIT 437 <br /> LRS <br /> HL TANK USE AND CONTENTS <br /> TANK USE a.MOTOR VEHICLE FUELING E3 1b.MARINA FUEL.NG ❑ la AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(tnckWa Used 09) ❑ 5.EMERGENCY GENERATOR FUEL IWC§24281-SWI 439a <br /> ❑6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑99.OTHER(Specify): 440 <br /> CONTENTS PETROLEUM: [3Ic.MIDGRADE UNLEADED lh PREMIUM UNLEADED <br /> ❑ 3.DIESEL ❑5.JET FUEL ❑6.AVIATION GAS 440a <br /> ❑ s.PEMLE13LENDFUEL ❑9.OTHER PETROLEUM Specif <br /> UM <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ IQ ETHANOL 440b <br /> U.OTHER NON-PETROLEUM <br /> IV. TANK CONSTRUCTION <br /> 443 <br /> TYOF TANK 1.SINGLE WALL .DOUBLE WALL 95.UNKNOWN <br /> LE <br /> PRIMARY CONTAINMENT STEEL 3.FIBERGLASS ❑&INTERNAL BLADDER 444 <br /> t7.STEEL+INTERNAL LINING [395.UNKNOWN ❑ 99.OTHER ( ): 444a <br /> SECONDARY CONTAINMENT ❑ i.STEEL FIBfiRGI ASS �EXTERIOR MEMBRANE LINER ❑7.JACKETED 445 <br /> [390.NONE 95.UNKNOWN 99.OTHER 445a <br /> OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR fi7CEMP nON FROM OYMILL PREVENITON EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑I.SINGLE WALLfiD IX)UBLE-WALLED ❑99.OTLffit °58 <br /> SYSTEM TYPE PRESSURE 2.GRAVITY 3.00NVEMIGNALSUCTION 4.SAFE SUCTION 23 CCR ax3) 4644 <br /> 46 <br /> PRIMARY CONTAINMENT L] 1.STEEL ❑4.FIBERGLASS 138.FLEXIBLE ❑ 10.RIGID PLASTIC <br /> 4641 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99• Spee ): 464h <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46t <br /> 464c0 90.NONE ❑ 95.UNKNOWN [399.OTHER(S ): <br /> PLPINGITURBINE CONTAR AENT SUMP TYPE 1.SLNGLE WALL 2.DOUBLE WALL 90.NONE 4 <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL k FIBERGLASS U 10.RIGID PLASTIC E3 90L NONE 0 99-OTHER(Specify) 464e <br /> 464et <br /> VENT SECONDARY CONTAINMENT ❑ 1.-STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99-OTHER(Specify) a64fl41 <br /> VR PRIMARY CONTAINMENT 13 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.(YTFffit(Specify} 4M6 <br /> l <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 10 RIGIDPLASTIC 90.NONE ❑ 99.OTHER(Specify) e64h <br /> 464ht <br /> VENT PIPING TRANSITION SUMP TYPE I E WALL 2.DOUBLE WALL 9Q NONE 464' <br /> RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 1Q RIGID PLASTIC 90.NONE 99.OTHER(Spectfy) <br /> RISER SECONDARY CONTAINMENT I.STEEL [34.-FIBERGLASS 10.RIGID PLASTIC jk9O.NONE 0 99 OTHER(Specify) 46vc <br /> 464k1 <br /> MPONEN <br /> FELL COTS INSTALLED 1.W1 L BUCKET STRIICERPLATFAlanOMPROTECfOR 0 4.CONT SUMP 451ac- <br /> VIL UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE SINGLE WALL (32.DOUBLE WALL [33.NO DISPENSERS 13�.NONE 46Ba <br /> °mho <br /> CONSTRUCTION MATERIAL 1.STEEL 4.FIBERGLASS 101Q RIGID PLASTIC 99.OTHER( ) <br /> CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448 <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,accurate, <br /> andA-fu-1hpuipliance wbMegal requirements. 470. <br /> APPLICANT SIGMA DATE /� <br /> (/ 471 <br /> APPLICANT NAME(P6) `/,r /� 471. APPLICANT TITLE <br /> UPCF UST-B-1/2 Rev.(12/2007) <br />