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UNIFIED PROGRAM CONSOLIDATED FO j UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT �3.RENEWAL PERMIT5.CHANGE OF El 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL INFORMATION DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 430b L`FAEIIITY II�IFORMATION, FACILITY ID#(Agency Use Only) I U BUSINESS N y (Same as FACILITY N or D -Doing Business As) _ rr 3 BUsnVEss s . D s � � �,�i c,� �.v% 104 N VU cue C�wt�e� t S �- C_ �l S ZD To H.TANK DESCRIPTION TANK ID# 432 'I ANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 ^X/ a1.A STAND-ALONE TANK VSo ! 'e rye-S [12.ONE IN A COMPARTMENTED UNIT. cmwifft ons PW sur eacb Compampent in su mriL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 L pbU III:1'ANK USE.AND CONTENTS TANK USE J&Is.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ie.AVIATION FUELING 439 [3 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE gwb dm Used oiQ ❑5.EMERGENCY GENERATOR FUEL[HSC§2528I.Xc)] ❑ 6.OTHER 22MMORFUEL ❑ 95.UNKNOWN ❑".OTHER(Specify): 4391 CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 ❑3.DIESEL ❑ 5.JET'FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON PETROLEUM:❑ 7.USED OIL 10.ETHANOL El 11.OTHER NON-PETROLEUMS : 4401 1W,TANKCONSTRUCTION TYPE OF TANK L SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS L3 6.INTERNAL BLADDER 444 ❑7.STEEL+IF1•ERNAL LINING ❑95.UNKNOWN ❑99.OTHER S 444a SECONDARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑6.EXTERIOR MEMBRANE LEVER ❑ 7.JACKETED 445 ❑90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 4451 OVERFILL PREVENTION 1•AUDIBLE 8c VISUAL ALARMS 2.BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452. ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT' PIPING CONSTRUCTION ❑1.SINGLE-WALLEDPO�R2.DOUBLE-WALLED, L3 99 O'ER UCTION 460 SYSTEM TYPE 1.PRESSURE 2.GRAVITY IiK3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION CCR§2636(1x3)] 458 PRIMARY CONTAINMENT 0 1.STEEL FIBERGLASS [18.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S fy): 464a SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE DI.J.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 464d "NEW,VAPOR RECOVERY"")"A MIZLSER I l PIPE PIPING CONSTRUCTIQN VENT PRIMARY CONTAINMENT 1.STEEL W 4.FIBERGLASS 0 10.RIGIDPLASTIC 90.NONE 0 ".OTHER(Specify) 464e 464et VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE U 99-OTHER(Specify) 464f VR PRIMARY CONTAINMENT 464n ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464, VR SECONDARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC NONE ❑ 99.OTHER(Specify) 464b VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL NONE 464ht RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE99.OTI3ER(Specify) 464j RISER SECONDARY CONTAINMENT STEEL 4.=SS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTAL LED1.SPILL.BUCKET 3.STRTER PLATFJBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4514ak-e VII.UNDER".DLSP$Wi QONFAINMENT.(ITRCj - CONSTRUCTION TYPE SINGLEW [32.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS 13 10.RIGID PLASTIC ❑".OTHER 4696 c . , . '. VIIt. CQRROSION,PR�M'EECTION [APPLICANT EEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPIWANI'�SIGNATURE RTIFICATION:I eerdfy that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with al requirements. PLICANT SIGNA DATE 311S O 470. i N tl 471. APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(1212007)