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p.4 01 RZ SIFIED PROGRAM CONSOLIDATED UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST pennanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION rl 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use onk) 1 F O o 1 - os- BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 8 lir BUSINESS SITE ADDRENS p 103 CITY ff 104 itif O GQ� IX.TANK DESCRIPTION TANK ID 9 432 TANK MANUeACTURER 433 TANK CONFIGURATION: TENS TANKIS 434 7 1.A STAND-ALONE T NC 'A ad�j-�� 2.ONE IN A COMPARTMENTED UNIT. Com tete ore fn each anmens in the unit. DATE UST STE. NSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 S 23 III.TANK USE AI`D CONTENTS., TANK USE jff la.MOTOR VL-HICLE FUELING ❑ Ib._VIARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inelades Used Oil) ❑ S.ENIERGE.NCY GENEMATOR FUEL 1HSC g25281.51c)I [36.OTHER GENERATOR FUEL ❑ 95.U14KI40WN ❑ 91).OTHER (Specify): 439a CONTENTS PETROLEUM: ar la.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ Ib.PREMIUM L-4LEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.?ETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV TANK CONSTRUCTION TYPE OF TANK I.SNGLE WALL 2.DOUBLE WALL ❑ 95.U\'KNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4" ❑ 7.STEEL-MTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4442 SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED "s ❑ 90.NONE -(] 95.UNKNOWN ❑99.OTHER( ecif y. 433a OVERFILL PREVENMON ❑ 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT _3.FILL TUBE SHUT-OFF VALVE 452• ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT:]WASTE PIPWG CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED 2.DOUBLE-WALLL"D [1911.OTHER 460 SYSTEM TYPE IN 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCIt 1253eraV)I 458 PRIMARY CONTAINMENT ❑ I.STEEL K 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.L•NKNOWN ❑ 99.OTHER(Specify)- 464a SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): PIPINGlTURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL [1 2.DOUBLE WALL Cl 90.NONE 464d VI.VENT,VAPOR RECOVERY.(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT [ ].STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464C 464el VB\TI SECONDARY CONTAINMENT ❑ L STEEL Wt 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f .watt VR PRIMARY CONTAINMENT J9 L STEEL ❑ 4•FIBERGLASS ❑ 10.RIGID PLASTIC E3 90.NONE 99.OTHER(Specify) 446 e VR SECONDARY CONTAINI LENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ la RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464h 464h1 VE\T PIPING TRANSRION SUMP TYPE ❑ 1.SINGLE W&LL ❑ 2.DOUBLE WALL Im 90.NONE 464i. RISER PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ t0.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(SpcciFy) 4641 4661 RISER SECONDARY CO'ITAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS lR RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) •64k 464k1 FILL COMPONENTS!NSTALLED :.SPILL BUCKET .STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENN'f SUMP 453a c _ VM UYDER DISPENSER CONTAINMENT(UM) . CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469'' CONSTRICTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTHER(Specify) 469b6c VIII. QRRIOSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. M APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, and in full com liance ' h legall reguirements. ago APPLICANT SIGNATURE DATE / V APPLICANT NAME(print) ` j 471' APPLICANT TITLE�Cn ;n UPCF UST-11-V2 Rev.(1212007)