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From 11/03/2008 15 38 #164 P 018/033 E J METED PROGRAM CONSOLIDATED Ft.-N UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Chec[c one item only. Foran UST permanent closure or removal,complete only this section and Sections I,II,Ili,1V,and IX below} J430 I NEW PERMIT ❑ 3.RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4303 1.DATE EXISTING UST DISCOVERED: bi IA 43ob I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Sane as FACILITY NAME or DBA•Do"ng Business As) 3 BUSINESS SITE ADDRESS Io3 CITY tr>e b II.WANK DESCRIPTION TANK ID# d12 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 �j �� ` � i th� ©I A STAND-ALONE TANK (�' iJ(,( G( 192.ONE IN A COMPARTMENTED UNIT COMIdC OM PORC fa tach can I in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBEROF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE Ia.MOTOR VEHICLE FUELING Q Ib.MARINA FUELING ❑ Ic.AVIATIONFUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE Q 4.HAZARDOUS WASTE(includes Used Oil) Q 5.EMERGENCY GENERATOR FUEL[HSC¢2528 t 5(e)) ❑ 6.OTHER GENERATOR FUEL Q 95.UNKNOWN ❑ 99.OTHER (Spec!fy): 439a CONTENTS PETROLEUM: ❑ Ia,REGULAR UNLEADED ❑ IC.IIIIDGRADEUNLEADEDib.PREMIUM UNLEADED t g/ 440 [33.DIESEL [35.JET FUEL 6.AVIATION GAS Q 8.PETROLEUM BLEND FUEL Q 9,OTHER PETROLEUM (Specify): 4404 NON-PETROLEUK J.USED OIL to.ETHANOL Q 1 L OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK El I.SINGLE WALL 2.DOUBLE WALL ❑95.UNKNOWN 443 PRIMARY CONTAINMENT I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 Q J.STEEL*INTERNAL IJNING [] 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT I.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ J.JACKETED 445 Q 90.NONE Q 9$.UNKNOWN ❑99.OTHER(S ecif : 4453 OVERFILL PREVENTION ag 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT IS 3.FILL TUBE SHUT-OFF VALVE 432 © 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION C3 1.SINGLE•WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1,PRESSURE E32.GRAVITY [23.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR¢2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 © 90.NONE ❑ 9$.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 0 8.FLEXIBLE I=I 10.RIGID PLASTIC 464b ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4641 PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE\VALE 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL W 4.FIBERGLASS 0 10.RIGID PLASTIC 1 9o_-NONE, U 99.OTHER(Specify) 464c 464et VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 4641 46411 VR PRIMARY CONTAINMENT ❑ 1 STEEL P6 4.FIBERGLASS ❑ 10.RIGID PLASTIC D 90.NONE ❑ 99.Mwit(Specify) 4648 464 t VR SECONDARY CONTAINMENT ❑ 1.STEEL V4.FIBERGLASS ❑ 10.RIGIDPLASTIC 0 90.NONE 13 99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 19 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS Lj 10.RIGID PLASTIC ❑ W NONE 0 99.OTHER(Specify) 464j 464 I RISER SECONDARY CONTAINMENT 1.STEEL J9 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.0THER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET El 3.STRIKER PLATEIBOTTOM PROTECTOR A.CONTAINMENT SUMP 451aa VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL V 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 9o.NONE 469a CONSTRUCTION MATERIAL ❑ 1.SPEFL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 99.OTHER(S cif 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODF(S) ❑4.IMPRESSED CURRENT 6.ISOLATION 443 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with le al relgiskAments. APPLICANT SIGNATURE DATE / 3 470 a APPLICANT NAME(print),, 4k471 APPLICANT TITLE 472 Y. e�