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UN 10ME D PR - CONSOLIDATED FORM UNDERGROUNDSTORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form Per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1, 11, III, IV, and IX below) 430 0 1, NEW PERMIT 0 3. RENEWAL PERMIT 5. CHANGE OF INFORMATION Ej 6. TEMPORARY UST CLOSURE [3 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL 430h. DATE UST PERMANENTLY CLOSED: 430a DATE UST DISCOVERED: I. FACILITY INFORMATION I. FACILITY ID # (Agency Use Only) BUSINESS NAME (Sape as Facility Name or DBA - Doing Business As) 3. 103 BUSINESS SITE ADDRESS 104. CITY 5]U 0 0 II. TA14KDESCMPTION ' TANK ID # 432. TANK MANUFACTURER 433. M 0 URATION: THIS TANK IS 434, -;r,4 V I ql,7PI 0 h)&& g ACT=ALONETANK cmoete� page for e=h 2. ONE IN A COMPARTMENTED UNIT comPmumm in the taft DATE UST SYS TALLE 435- TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS IN THE UNIT 437. T 7 ).�. 0 90 M. ANK USE AND CONTENTS TANK USE 0 1& MOTOR VEHICLE FUELING 0 lb. MARINA FUELING Ic. AVIATION FUELING 439. 'BAERGENCY GENERATOR FUEL W §25291,5(c)) 0 3. CHEMICAL PRODUCT STORAGE 0 4. HAZARDOUS WASTE (Indadw and 0d) 5. EMERGENCY 0 6. OTHER GENERATOR FUEL 0 95. UNKNOWN 0 99- OTHER (Spedfy): 439. CONTENTS PETROLEUM: [I Ia. REGULAR UNLEADED 0 Ic. MIDGRADE UNLEADED 0 1 b. PREMIUM UNLEADED 440. 0 3. DIESEL FY5. JET FUEL ❑ 6. AVIATION GAS [18. PETROLEUM BLEND FUEL 9, OTHER PETROLEUM (Specify): 440a. -140-N-P C-TROLEUM: El 7. USED OIL ❑ 10. ETHANOL 0 11. OTHER NON -PETROLEUM): 440b. IV. TANK CONSTRUCTION TYPE OF TANK El 1. SINGLE WALL 10.2. DOUBLE WALL 0 95. UNKNOWN 443. PRIMARY CONTAINMENT 13 1. STEEL 3. FIBERGLASS [] 6. INTERNAL BLADDER 444. 0 7. STEEL+ LINING 0 95- UNKNOWN 0 99. OTHER (Specify): 444a. SECONDARY CONTAINMENT [3 1. STEEL 3. FIBERGLASS 0 6. EXTERIOR MEMBRANE LINER [1 7. JACKETED 445. 0 90. NONE -M-95. UNKNOWN 0 99. OTHER (Specify): 445. OVERFILL PREVENTION 0 1. AUDIBLE & VISUAL ALARMS 0 2. BALL FLOAT 0 3. FILL TUBE SHUT-OFF VALVE 452, Q 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0, 1. SINGLE WALL F2. DOUBLE WALL 0 99. OTHER 460. SYSTEM TYPE tESSURE 2. GRAVITY [1 3. CONVENTIONAL SUCTION 0 4. SAFE SUCTION [23 ccR §2636(.)(3)1 458, PRIMARY CONTAINMENT [3 1. STEEL 4. FIBERGLASS 0 8. FLEXIBLE 0 10. RIGID PLASTIC 44 A957UNKNOWN 0 90. NONE 0 99. OTHER (Specify)- 464& SECONDARY CONTAINMENT ❑ 1. STEEL P&4. FIBERGLASS 0 8. FLEXIBLE 0 10. RIGID PLASTIC 464b. 90. NONE [3 95. UNKNOWN 0 99.OTHER (Spdfyy 464c PIPING/TURBINE CONTAINMENT SUMP TYPE 0 1. SINGLE WALL n 2. DOUBLE WALL 0 90. NONE 464cL VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT V 1.STEEL[14- FIBERGLASS 0 I0.RIGID PLASTIC 0 90. NONE E] 99. OTHER (Specify): 464e. el. VENT SECONDARY CONTAINMENT d 1. STEEL 0 4. FIBERGLASS 0 10, RIGID PLASTIC ❑ go. NONE [] 99. OTHER (Specify): 4W 464n. VR PRIMARY CONTAINMENT 0 LSTEEL 0 4. FIBERGLASS 0 H).RIGID PLASTIC ❑ 90, NONE 0 99. OTHER (Specify): 464& 464PI. VR SECONDARY CONTAINMENT 0 i. STEEL E34. FIBERGLASS 0 10.RIGID PLASTIC 0 90. NONE 13 99. OTHER (Specify):464464h�hi. VENT PIPING TRANSITION SUMP TYPE El 1. SINGLE WALL [] 2- DOUBLE WALL 0 90 NONE 4641. RISER PRIMARY C 0 1. STEEL 0 4- FIBERGLASS 13 10. RIGID PLASTIC [3 90. NONE 0 99. OTHER (Specify): 464j. 4CAj I RISER SECONDARY CONTAINMENT 1. STEEL [1 4. FIBERGLASS 13 lo- RIGID PLASTIC o 90. NONE [3 99. OTHER (Specify): 464k. 4641 FILL COMPONENTS INSTALLED 1. SPILL BUCKET [1 3. STRIKER PLATE/BOTTOM PROTECTOR [1 4. CONTAINMENT SUMP 451a -c. Vil- UNDER DISPENSER CONTAINMENT (UDQ CONSTRUCTION TYPE El I. SINGLE WALL -0 2. DOUBLE WALL -[1 3. NO DISPENSERS 90. NONE 469& - CONSTRUCTION MATERIAL 0 1. STEEL 0 4. FIBERGLASS [3 10. RIGID PLASTIC 0 99. OTHER (Specify) -460b- 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 13 2. SACRIFICIAL MODgS) Q 4. IMITESSED CURRENT 13 6. ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hurdons substance stored and that the information provided herein is true, accurate, and in full compliance with legal reauirements. APPLICANT SIGNATURE DATE 470. _2 / 0 APPLICANT NAME (print) 471 1��6ddv 10, All, APPLICANT TITLE 472. /A0 W141"411M, UPCF UST -B Rev. (11=94 -112 www.unidoeLorg