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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usTyC / TYPE OF ACTION (Check am item only. For an UST pmu ml domm or removal,comPklc 0*tris section and Sem 4 K HL IV.mW IX bek-) 430 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF 0 FORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENMY CLOSED: 4Ra I DATE EXISTING UST DLSCOVERED: 4 LFACIi.IPY INFORMATION`' - FACHM ID#(Agemy UseOwly) t BUSINESS NAME(Same as FACHnY NAME or DBA-Doug Hum=As) 3 W BUSINESS SITE ADDRESS las CITY 104 II.:TANKDF�CRiPTiON TANK ID#-r%P5107 91, 42 TANK MANUFACTURER ui TAW CONFRIURATTa1N'.TUB TANKS 434 ❑1.A STANDALONE TANK R4C�CT 2.aNE naw COMPARTMENTED UNIT. ooe f0rQKb i0 00k DATE AiJ,(:D TANK ACLIY IN GALtAW 4M NUMBER OF ARTMENTS IN THE UNfT 437 111TANKUSEANiComENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ih MARINA FUEL NG (3 la AVIATION FUE LING 439 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(hxiWe tlm dUa) ❑5_EMERGENCY GENERATOR FUEL(HSC IM9Is(e)] 136.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 99.OTHER( ): 439a CONTENTS PETROIEUAf: ❑ la.REGULAR UNLEADED ❑ lc.MMGRADE UNLEADED ❑ Ih PREMIUM[UNLEADED 440 jV 3.1) SEL ❑5.JET FUEL ❑A AVIATION GAS ❑8.PETROLEUM BLEND FUEL El9.OTHER PETROLEUM 440a ❑7.USED OI. ❑ 10.ETHANOL ❑ 11.OTHER TION PETROLEUM 440b Ifs TANK:_: TYPE OF TANK El 1.SOME WALL 2.DOUBLE WALL 9S.UNKNOWN 443 PRIMARY CONTADMIENT L3 1.STEEL. $j 3.FIBERGLASS 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER S 444a SECONDARY CONTAINMENT ❑ 1.STEEL ,9 I FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 13 90.NONE ❑ 95.UNKNOWN ❑99.OTHER ): 445a OVERFILL PREVENTION 1.AUDIBLE A VISUAL ALARMS 2 BALL FLOAT 3.FILL TUBE SHUTT-0FF VALVE 452 4.TANKMBEIS REQUIROMENTS40R.INION FROM OVERFILL PREVENTION V:-�'ItODIi(Tl RARiE APING SUmW-l-- PIPI NG CONSTRUCTION Q L SINGLE-WALLED IN 2 DOUBLE-WAIL IDEJ 99 DIRER gdp SYSTEM TYPE L PRESSURE ❑7-GRAVITY El 3.CONVENTIONAL SUCTION-Cr-4.SAFESumoNp3OCR i2636(ax3) 438 PRIMARY CONTADM ENT LEI I.STEEL 4.FIBERGLASS ❑II FLEXIBLE 13 10.RIGID PLASTIC 464 ❑90.NONE 95.UNKNOWN ❑99.OTHEWAwcifYr 464& SECONDARY OONTAI IGEN l' ❑ 1.STEEL 4.FIBERGLASS ❑R.FLEXIBLE 0 10.RIGID PLASTIC 4646 ❑90.NONE ❑95.UNKNOWN ❑99.OTHER(Spacily) 464c PIPlNGtTURBINE CONTAIRAE1 T SUA/P TYPE 0 1.SINGLE WALL 2.DOUBLE WALL Cl 90.NONE 464e [ BL QVI �1 RiS� : iE. .E PE.PIPIlYG G�ucno •. VENT PRIMARY CONTAI&LENT EJ L STEEL 4.FIBERGLASS U I0.RKIID PLASTIC 90.NONE 0 99 OTHER(Specify) 464& 464e1 VENT SBGONDARY C NTAINMEINI U I.STEEL 4.FIBERGLAS'S 10.RIGID PLASTIC jV 90.TIONS E3 99.OTHER(specify) 464f 46411 VR PRIMARY CONTA(NMENf 1.STEEL. 4.FIBERGLASS 0 l0.RIGIO PLASTIC 13 90.NONE 0 ".OTHER(specify) 464g VR SE(:ONDARY CONTAINMENT ❑ L STEEL 13 4.FIBERGLASS ❑ lo.RIGIDPLASTIC 9o.NONE ❑ 99 OTHER(specify) 464h VENT PIPING TRANSITION SUMPTYPE t.SINGLE WALL Z DOUBLE WALL 4664ht 90.NONE 464L RISER PRA IARY CONTAINIAENf 191.STEELE3 4.FIBERGLASS El 10.RIGIDPLASTIC 90.NONE 1399.OTHER(specify) 464j 464"1 ROM SECONDARY CONTAROCENi 1.STEEL 4.FIBERGLASS It=0 PLASTIC 90.NONE El 99.OTHER(Specify) 464k 4641 FILL COMPONENTS E3 1.SPILL BUCKET El 3.STRIKER PLATL%IIOTTOM PROTBCTOR 4.CONTAINMENT SUMP 451a-c VIIC'Ul!iDER'INSP .WO_' CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 46% CONSTRUCTION MATERIAL 1.STEEL 0 4.FIBERGLASS 13 10.RIGID PLASTIC Q99.OTHER( ) 469be M CORR06ION I+R[ _gCTION STEEL COWON]ENP PROTBCI'ION ❑2 SACRIFICIAL ANODES) ❑4.IMPRESSIO CURRFdNT ❑6 ISOLATION 44& _ISL APPLICANT�t�iA�QRE CERTUgCATION.-I arfify UST is COmpat"wit Hie ba un&n sobd nce ataed alai fiat tie i irsstion anti in pr4►vidcd Ile i8. a4xarate, APPLICANT SIGNATURE DATE r 470• O LFA; r APPLICANT NAME(part) 471.� Qr APPLICANT TOILE 6 W � ar-. UPCF UST-B-1/Z ��.`� Rev.(12/2007)