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UNIFIED PROGRAM CONSOLEI)ATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) W • DATE EXISTING LIST DISCOVERED: 430b. M 4 64 lij as)t4a ny 0 jw�� BUSINESS SITE ADDRESS 103. 1 1 1501 NORTH JACK TONE ROAD 10. 19 H. TANK DESCRIPTION 4UFACTURER 49-- ;, TANK CONFIGURATION:THIS TANK IS 434. �ENS CORNING '1! 19 1.A STAND-ALONE TANK compkicaftepascibrefth i Q 2.ONE IN A COMPARTMENTED UNIT companinew in the unh. rrY IN GALLONS 6- NUMBER OF COMPARTMENTS IN THE UNIT 437. DATE UST SYSTEM INSTALLED TANK CAP - 43 12/1994 20,000 M. TANK USE AND CONTENTS I TANK USE 0 1 a.MOTOR VEHICLE FUELING 0 •lb.MARINA FUELING [3 Ic.AVIATION FUELING 439. 0 3.cHEmir-AL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(includes Used Oil) 0 5,EMERGENCY GENERATOR FUEL[HSC#2518t.S(c)l El 6.OTHER GENERATOR FUEL 0 95.UNKNOWN El 99.OTHER(specify): 439L CONTENTS PETROLEUM: ■ Is.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED lb.PREMIUM UNLEADED 440. 3.DIESEL El S.JET FUEL ■ 6.AVIATION GAS Q 8.PETROLEUM BLEND.FUEL El 9.OTHER PETROLEUM(Specify): 44h. NON-PETROLEUM:0 7.U-SED OIL U 10.ETHANOL 171 If.OTHER NON-PETROLEItM(Speecdi 440b. R IV. TANK CONSTUCTION _tVFE OF TANK 0 1-SINGLE WALL N 2.DOUBLE WALL 0 95.UNKNOWN 443. PRIMARY CONTAINMENT Ll LSTEEL N 3.FIBERGLASS 0 6.INTERNAL BLADDER 4447 7.STEEL+INTERNAL LINING.., 11 95.UNKNOWN 0 99.OTHER(Specify): 444s. SECONDARY CONT MENT [I LSTEEL 0 3.FIBERGLASS [3 6.EXTERIOR MEMBRANE LINER KE 445. Q 90.NONE 0 95.UNKNOWN [3 99,OTHER(Spe■ cify), 0 7.JAC TED 445a. OVERFILILPRtYE ENTION 1.AUDIBLE&VISUAL ALARMS [3 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. -4.TANKMEETS EQUIREMENTS FOR EXEMPTION FROM OVERFILLPREVENrION EQUIPMENT NYSTEM TYPE 1.PRESSUR 0 2.GRAVITY El 3.CONVENTIONAL SUCTION 0 4.SAFfibCT1&I23CCR§2636(aX3)I 458. PRIMARY CONTAINMENT n 1.STEEL N 4.FIBERGLASS C1 8,FLEXIBLE 0 10.RIGIDPLASTIC 464. 0 90.NONE 11 95.UNKNOWN [1 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT 0 1.STEEL AD 4.FIBERGLASS [3 &FLEXIBLE 0 10,RIGID PLASTIC 464b. 1:3 90.NONE 95.UNKNOWN 0 99.OTHER(Speciry): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WALL 464d. 90.NONE VI. VENT,VAPORRECO KRY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT El 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4 c. 464cl. VENT SECONDARY CONTAINMENT [3 LSTEEL 0 4.FIBERGLASS [3 to. [1 99.OTHER(Specify): 46411.- RIGID PLASTIC r_1 go.NONE �64f. VR PRIMARY CONTAINM-ENT Ll LSTEEL R 4.FIBERGLASS [3 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): VR SECONDARY CONTAINMENT 0 1.STEEL IM 4.FIBERGLASS [3 10.IUGM PLASTIC 0 90.NONE 0 99.OTHER(Specify): -464hl. VENT PIPING TRANSITION SUMP TYPE 181 1.SINGLE WALL E3 2.DOUBLE WALL [1 90,NONE 464L RISER PRIMARY CONTAINMENT 0 LSTEEL IM 4.FIBERGLASS 0 10.RIGID PLASTIC [3 90.NONE 0 99.OTHER(Specify)- RISER SECONDARY CONTAINMENT [3 1.STEEL 19 4.FIBERGLASS 0 10.RIGID PLASTIC [3 90.NONE 0 99.OTHER(Specify): FILL COMPONENTS _iek�l TNSTX_�E ED 1.SPILL BUCKET 0 3.STRIKER PLATFjBO • PROTECTOR 0 4.CONTAINMENT SUMP 45la-c. mire)U-4 I jorek AN171 a VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION El 2.SACRIFIC!AL ANORE(a ■ 4.IMPRESSED CURRENT ■ ISOLATION IX. APPIJCANT SIGNATURE CERTIFICATION: I ccrtif� that this UST systei" atible with the hazardous substance stared and that the information provided herein is true, accurate,and in fun compliance with legal reqM1 APPLICANT SIGNATURE 07-0 , DATE 09/18/2008 APPLICANT TITLE DIRECTOR OF HS&E APPLICANT NAME(print) JEFF LARSEN iiiiiiiiiiii 1111�1�jpqiii