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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per US TYPE OF ACTION (Check one item only. Foran UST permanent closure ornmeaval, complete only this section and Sections I. IL III, IV, and IX below) 430 L NEW PERMIT U 3, RENEWAL PBRMIT 5, CHANGE OF INFORMATION 6. TEMPORARYUSTCLOSURH ❑ 7, USTPERMANENT CLOSURE ON SITE B. UST REMOVAL DATE UST PERMANENTLY CLOSED: k) 43on DATE EXISTING UST DISCOVERED: mob I. FACILITY INFORMATION FACILITY ID 4 (agency Use, Only) _ _ 1 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 CITY I04 II. TANK DESCRIPTION TANKIDV // asz TANK MANUFACTURER 433 ®TANKCONFIGURATION: THISTANKE 434 J LASTAND-ALONETANK Cl [12. ONE INA COMPARTMENTED UW . Complete one for coh co eotln theerit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT air III. TANK USE AND CONTENTS TANK USE U Ia. MOTORVEHICLEFUELMO U 1b.MARINAFUELING U 10. AVIATIONFUELING 439 U 34 CHEMICAL PRODUCTSTORAGE 44. HAZARDOUS WASTE Mdudw Used oil) ❑ 5, EMERGENCY GENERATOR FUEL RISC Eo32BL3(c)J U 6. OTHERGfiNERATORFUEL 95. UNKNOWN U 99, OTHER (Specify): 4391 CONTENTS PETROLEUM: U Is. REGULAR UNLEADED U 10. MIDGRADEUNLEADIvU ❑ Ib. PREMIUMUNLEADED 44a U 3, DIESEL [� 5. )ETFUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL �jr 9. OTHER PETROLEUM (S eciT ): 4402 NON-PETROLEUM: 7, USED OIL ❑ 70. ETHANOL I. OTHERNON•PHTROLEUM (S mi ): Mob IV. TANK CONSTRUCTION TYPEOFTANK t. $NGLEWALI. U2, DOUBLEWALL U95. UNKNOWN 443 PRIMARY CONTAINMENT I. STEEL U 3, FIBERGLASS ❑ 6. INTERNAL BLADDER 444 U 7, STEEL+ INTERNAL LINING ❑ 95. UNKNOWN , ❑ 99. OTHER (S edfy): 4 ft SECONDARY CONTAINMENT U LSTEEL 03, FIBERGLASS U G. EXTERIOR MEMBRANE LINER U 7. IACKETED 445 NONE ❑ 95. UNKNOWN ❑ 99, OTHER (3 eci, ); u51 OVERFILLPREVENTION 1. AUpIBLE &VISUALALARMS 2. BALLFLOAT' El IFILL TUEE SHUT-OFFVALVE 452, )� 4. TANK MGETS REQUHtEM1IIi1tTS FOR fiXEMPTTONFROMOVERFMLPREVENTTONEQUII>MENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION U ), SINGLE-WALLBD 02. DOUBLB•WALLED IA 99, OTHER Oso SYSTEMT PPE U 1. FRESSURE ® 2. GRAVITY U 3, CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR 3636(.)(3)] 45s PRIMARY CONTAINMENT U I, STEEL ❑ 4, FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 Iff 90, NONE U 95, UNKNOWN U 99. OTHER(Sped ); 464. SECONDARY CONTAINMENT U LSTEEL U 4. F18ER0LASS U & FLEXIBLE U 10, RIGIDPLASTIC 4646 U 90.NONE U 95. UNKNOWN ❑ 99, OTHER (Specify): 4640 PIPN ITURBINECONTAINMENTSUMP TYPE U I. SINGLE WALL � 2. DOUBLE WALL 90. NON8 464. VL VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VEN' PRIMARY CONTAINMENT U I. STEEL U 4, FIBERGLASS U 10, 1k1U1DPLA3TIC M W. NONB U 99, 0171ER (Spec(fy) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLAS S ❑ 10, R10Ip PLASTIC ® 90, NONP � 99. OTHER (SpeeiTy) 4644 VR PRIMARY CONTAINMENT U 1, STEEL 4. FIBERGLASS .EI 10. RIGID PLASTIC ix 90. NONE U 99. OTHER (SpW y) 4640 VR SECONDARY CONTAINMENT l] 1, STEEL U 4. FIBERGLASS ❑ 10. RIGIDPLAST [C 990, NONE ❑ 99. OTHER (Specify) 464h VENTPIPIN 7RANSI'TION SUMP TYPE 1. SINGLE WAW. ❑ 2. DOUBLE WALL {¢} 90. NONE h444t ]USSR PRIMARY CONTAINMENT U 1, STHEL 4. FIBBRGLASS ❑ 70. RIGID PLASTICA90, NONE ❑ 99. OTHM (Spedfy) 46/j 464'1 RISER SECONDARY CONTAINMENTU L STEEL U 4. FIBERGLASS D 10, RIGID PLASTIC 90. NONE Q 49. OTHER (Specify) 464k 4640 FILL COMPONENTS INSTALLED U LSPILLBUCKET LI 3. STRIKERPLATEMOTIOMPROTECTOR U 4. 17ONTAINMENTSUMP 451a< VII- UNDER DISPENSER CONTAINMENT (IJDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL U 2. DOUBLE WALL ❑ 3, NO DISPENSERS 90. NONE 46% CONSTRUCTION MATERIAL ❑ LSTEEL ❑ 4. FIBERGLASS U 10, RIGID PLASTIC ❑ 99, OTHER (Sied ) 46960 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION CRIFICIAL ANODE($) U 4, IMPRESSED CURRENT ❑ 6. ISOLATION 446 IX. APPLICANT SIGNA'T'URE CERTIFICATION: t that th BUST nem is compatible with the hazardous substance stored and that the information provided herein is true, accuratq and In II eom li ith legal requirements. APPLIC SIGN PATE �� Z l� 470 PPLICANT :! ) P .,p -.rcy� � 4r1 APPLICAN TI� ` 4T'• UPCF UST-B - 1/2 �/t Rev. (1212007)