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D PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPFRATING PERMT APPLICATION-TANK INFORMATION one form BE u TYPE OF ACTION (Ch9ck one item only. For an UST t cloacae or r=mL ca* only t6ta aeWon ad Se W ma I,I,111,N,and DC bdlver) 430 ❑ 1,NEW FERW ❑ 3.RENEWAL PElWT ❑ 3.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE: Q 7.UST PERMANENT CLOSURE ON SITE Q 9.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4146 DATE EXISTING U$T DISCO FACILITY ED p(agency Use Only) t BUSIMS NAM(Same as FACILITY NAME or DeA-Doing Batm As) 3 BUSLNESS SITE ADDRESS 163 CITY106 TANK ID " TANK MANUFACTURER 433 TANK cOI4FIWRATo N:T ws TANK is F34 ❑I.A STAND-ALONE TANK ❑2.ONE IN A C0MPARTMENTED UMI. rmma cum tbrwet cmurmmbaemdt DATE UST SYSTEM iNBTALLED 435 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS IN THE UNIT 437 TANK USE D is.MOTOR vaucLE FUBLIING^ ❑ lb.MARINA FUELING ❑ 1 c AVIATION FUEI RNO 439 ❑ 3.CNEMtCAL PRODUCT sToRAGE ❑4.HAZARDOUS WASTE(dam Veal G10 ❑ S.EM@RGEKY GENERATOR FUEL(HSC IMB I Ac)1 ❑ C OTHER GENERATOR FUEL ❑95.UNKNOWN ®99.OTHER 4'19c CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ lm MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 ❑3.DIESEL ® S.JSI FUEL ❑ L AVIATION GAS O B.PETROLEUM BLEND FUEL ® 9.OTHER PETROLEUM ae® NON-PETROLEUM:❑7.USED OIL 13 10.ETHANOL 11.OTHER NON-PETROLEUMS gab TX TYPE OF TANK L SINGLE WALL . 2.DOUBLE WALL Lj 03.UNKNOWN 443 PRIMARY CONTADDan ❑ L STEEL ❑ 3.FIBERGLASS ❑6.INTERNAL BLADDER 4" ❑7.SIEEt*INTERNAL LINING O 9S.UNKNOWN ®99.OTHER 4444 SECONDARY CONi'A1NME qr ❑ 1.STEEL ❑3.FIBERGLASS ❑6,E nMWR MEMBRANE LINER ❑ 7.JACKETED acs 90.NONE M 9S.UNKNOWN 9 99,OTHER am& 4Q4a OVERFILL PREVENTION 111.AUDIBLE R V ISUAL ALARMS ff 2.BALL FLOAT b 3.FLLL TUBE SHUT-OFF VALVE 452. ®4.TANK MEETS NTS FOR OtEMPTION PROM OVERFILL PREVENTION EMMM ... V: DIJG1`/� G�O1V��tUGTiIDN° PIPING CONS7RUCRION Q 1.SR40. -WALLED 0 L DOUBLEMALLFD 0 99.OTKUL 400 SYSTEM TYPE 12 1.PRESSURE 2.ORAviTY 3.CONVENTIONAL SUCTION E3 4.SAM SUCTION L23 Cts 2 3 do PRIMARY CONTAINMENT C3 I.STEEL L3 4.FIBERGLASS L3 S.FLIUMM ❑ 10.RIGID PLASTIC 46a ®90.111ONs ®9s.UNKNOWNN ®99.OTHERovalft 4" SECONDARY CONTAINMENT 13 T STEEL 0 4.FIBBROLAS$ S.FLEXIBLE E3 10.RJOID MASTIC 46U ❑go.NONE ❑95.UNKNOWN ❑99.OTIIER( )- 4o PMGfr=[NE CONTAINMENT SUMP TYPE 1.SINGLE WALL Q L DOUBLE WALL 90.NONE 4646 .VJsu.,' ',a'4tAP.t11I d _ '°1 O�GYyUCITO3�-. VENT PR2AARY CONTARNMENT Ll 1.STEEL 4.FIBERGLASS L3 10.RIGID PLASTIC U 90.NONE U 99.OTHER(SPmW a46 VENT SECONDARY CONTAINMENT 1.STEEL 4.FwzR63IA3S 0 NO-RIGID PLASTIC C3 90.NONE 15 99.OTHER(Spedt l 4w 4ten VR PRIMARY CONNTAD MENT Cl i.ST7aEt. El 6.FYBERGLASS J 0. om PLASTLC 0 90.NONE El 99.0THmt Owe) 4648 o6a t VR SECONDARY CONTAINMENT E STM JZ 4.FIBERGLASS 0 10.RIGID PLASTIC E3 90,NONE 99.t33IIER(SpmW eft 'VENT PIPING TRANST170N SUMP TYPE Q 1.SINGLE WALL Z DOUBLE WALL 90.NONE Ami. RJSER PRIMARY CONTAINMENT U 1.STEEL U 4.FIBERGLASS L3 10.RIGID PLASTIC 90.NONE E3 99.OTHBR(Sped*) 44 RISER SECONDARY CONTAINMENT El J,STEEL 4.FMBRMA33 J3 10.9-MPLASTIC 13 90.NONE 99.OTHER Me*) 46rt 4Akl FILL COMPONENTS INSTALLED I.SPILL BUCKET 3. PLATE/BOTIOM PRQIFCIOR 4.CQNTAINMENT SUMP 49 Ew ...... _ co CONSTRUCTION TYPE 13 t.STNGLE WALL ® 2.DOUBLE WALL ❑3.NO DISPENSES ❑90,NONE CONSTRUCTION MATERIAL 0 1.STEtI, E3 t0.RIG®PLASTIC "TMa2& 4646 c STEEL COMPONENT PkUrECT70N ❑2.SACRIFICIAL ANODEM ®4.IM112SSM CURRENT ❑6.TSOLATION •°& CERTEFICATION: I mrdfy that dik UST nyvem Is coapatilik with the Afas ami dot the Inkemadom prawkial heivib Ls tree,morale, and IIIful mokom wM 1 matilremmm APPLICANT SIGNATURE DATE moo' APPLICANT NAME(print) 471. APPLICANT TiILE 47Z UKT -I3-1/2 Rear.(1