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UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST)
<br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430
<br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION
<br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4706
<br /> sR..r ii)s�s a 6t tt.. tR a at fc �•.�_+'] 7Y* �Jp�7���+ est'YT N - }+ ,•y,'414•,y5'�"�i n jt•f _}r r C �, ;.r-:
<br /> pa a :br -rt r 4- a i ?:i.l-.. r``�i'�. •X.dj-LSCiLAT 1-
<br /> 2 .
<br /> FACILITY ID#(Agency Use Only)
<br /> � AOI':)•: n�` .1`
<br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3
<br /> Grant Line Shell 136187
<br /> BUSINESS SITE ADDRESS101 CITY 104
<br /> 2375 W.Grant Line Road Trac
<br /> F tTY r'J. rt ,rh.t k4 }7 trf,� ''4s r^K Z- �7'-[r Sgt y��!/'t { 'Y L' �a• 4'at.�17'(tk=,`f•.i�^�$,=t ylr <f try t i z }�.eks-4{ 3 t.•ya�Kt../;s
<br /> 1`7 3!"tix��.it 94�..r pAY IAY4I.i?i...J.,.S'� �'..�t(X.i1tt.�3Y•rKt�TJ".,i4x} "11--1 I]TI�76r to f.•3L i���� v..p.�`.�t:�.ki�4l*'r.�t?.�� 1.�Y,i..n A�d�}y.:tla'ad.+1A.%.
<br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434
<br /> 3-Premium Xerxes ®I.A STAND-ALONE TANK
<br /> ❑
<br /> 2.ONE IN A COMPARTMENTED UNIT.
<br /> Complete ace page for each compartment in the unit.
<br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437
<br /> 1991 is ta &•;.i5:�1200r0
<br /> 1 'JyP:+ Ai itS�.v+f�.>,,�!�}a ';U} '.•k�lD - }��1qTFiT;s v� ,ns��:J.l53
<br /> gr�3.•} .�r:�! 1
<br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC 125281.5(c))
<br /> [16.OTHER GENERATOR FUEL [195.UNKNOWN ❑ 99.OTHER(Specify): 4393
<br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ic.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440
<br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS
<br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a
<br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL
<br /> ❑
<br /> 11.OTHER NON-PETROLEUMS cif : Y 4406
<br /> ror13f ;d^,, ^�•W�{it;r}w'"`iili,,S:. .4b. •t4G,cJ; .;f<,;,3,r yi}."ra'�{y.}..� '. "mag�• r si:t�R'.,^.',:i&:cyaie?
<br /> e`.•.•�'t''S"r':L.?t�`.k-'R"A {'��j l: �1...;, ,.'}' t:'.+ •�rP' 0.
<br /> MIT
<br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443
<br /> PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify); 444s
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445
<br /> ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Seci ): 445a
<br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS &2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452.
<br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER 460
<br /> SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(s)(3)) 459
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c
<br /> PIPING(TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d
<br /> J Syy ` 7�rT �j�p�+t+(� v �+ �pL+: s(ry•(�}��`�{`�TT 7 gry r���• N m w
<br /> <;rt4`fi0 7?3_<..�[ 47 Aa'f,� -.JsQj:L�',�":ih"rYdTr.at4'+ •fir '�,.?. Ln.
<br /> egg,
<br /> g! 1r .9ro lteish$�• ho'.xi9.1&:rFt"'.A?.a{.''t�vYrt.� -.'.ti
<br /> VENT PRIMARY CONTAINMENT U L STEEL Dg 4.FIBERGLASS Lj 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e
<br /> 464el
<br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC C3 90.NONE El 99.OTHER(Specify) 464f
<br /> 464n
<br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE E3 99.OTHER(Specify) 4b44g
<br /> VR SI
<br /> SECONDARY CONTAINMENT 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h
<br /> 464h1
<br /> VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464L
<br /> RISER PRIMARY CONTAINMENT 99 1.STEEL Ll 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4641
<br /> 464'i
<br /> RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464k
<br /> 4641
<br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR 1@ 4.CONTAINMENT SUMP 451a•c
<br /> a.wr r•; 1 -h - ��7 t+ icy.(. 7i,,.�'' 4 �j y y �`t = Y J tyxrrr �+
<br /> UNDE12!DISP SL+R,I.® t; :':la°aa'lil �e� ;5,,`p)` 'a 't ^l.i � �` �;� ",'.�i'iSt} _�;
<br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE r 46%
<br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b•c
<br /> ;.Ir v a,rx 7r Mir Mk r 41�F�`'t (1��GORR®SIO b tE ION 4°'' raa
<br /> ? ;:t'=.r t.S F"Y.tlY t..,c`,W} .esti r:•4• J;S:z' A,.4;x ...3»• ,+ . .. � .. ,tt.;4. .r .r, =n r•'
<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448.
<br /> •�2>�t`� v xc4�"a.��t�J �l'� '�,_•, lxrt `,�'`Is���B5�7`f4.4tr )���}zpP;I� �.'E�+1,4?f�• � �,��N�� r I,j��k'�°mlu•. �1}. �.�1���iti���}t��r�i'S:,}t.x tq�t�s`inws
<br /> CERTIFICA ION: I certify that this T,''system is compatible with the hazardous substance stored and that the information provided herein is true,accurate,
<br /> • and in full om 1' n e with Ie a[re uirements.
<br /> LICA N T G� DATE 470'
<br /> 11/1112009
<br /> P NAME(pral4 471' APPLICANTTITLE 472.
<br /> Aura S• ley for Shell it Pr ducts US Shell Oil HS&E Coordinator
<br /> UPCF UST-B-2/4 Rev.(12/2007)
<br />
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