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�• Ir UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK " OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) // F TYP F ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, II, III, IV, and IX below) 430 10 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION El 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE C1 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: "oa DATE EXISTING UST DISCOVERED: 43ob I. FACILITY.INFOMATION FACILITY ID # (Agency Use Only) _ _I ( J6 BUSINESS NAME (Same as FACILITY NAME orPBA-Doing Business As) 3 l- CSL 0 P,l, 'tv R- �5-A-/ BUS2JESS SITE ADDRESS 1Q3 CITY n3 104 II:'TANICDhSCRIP°I'ION TANK ID/rI B 5, ,yL,5Z�rO 432 TANK MANUFACTURER 433 TANK CONFIGURATION: Tins TANx rs 1� 430 CC ❑ 1 A TANK P0�•LA m cNE INA COPARTMENTID UNIT. Omplae� pap Toroth cmparmicat mthe vaic DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBERO COMPARTMENTS IN THE UNIT 437 TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ !b. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (7dude Used Oi0 ❑ 5. WERGENCY GENERATOR FUEL (HSC 1252815(e)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN OTHER (Specify): 439a CONCENT$ PETROLEUM: ❑ la. REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ tb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440. NON -PETROLEUM: ❑ USED OIL ❑ 10. ETHANOL /7. 1. OTHER NON -PETROLEUM ): O (V 440b .: TANK CONSTRUCTION -. . TYPE OF TANK ❑ 1.,5%INGLE WALL go - DOUBLE WALL 13 95. UNKNOWN 443 PRIMARY CONTAINMENT LK. STEEL ❑ 3. FIBERGLASS ❑ 6. IIYTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ ".OTHER (S 444. SECONDARY CONTAINMENT . STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINIIt ❑ 7.lACRETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER (S445a ): IL OVERFL PREVENTION g 1. BLE S: VISUAL ALARMS 2. BALL FLOAT 3. FELL TUBE SHUT-OFF VALVE 452 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V; PRODUCT l WASTE MING �ONSTRU�TION :,` - PIPING CONSTRUCTION . SINGLE -WALLED Q 2 DOUBLE -WALLED Q 99. OTHER 460 SYSTEM TYPE UFWMURE ❑ 2. GRAVITY 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION p3 a3t vA36(alpll 458 PRIMARY CONTAINMENT STEEL ❑ 4. FIBERGLASS ❑ 8. FLERBiLE L3 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. peatty): 464a SECONDARY CONTAINMENT ❑ L STEEL. ❑ 4. FIBERGLASS 0 8. FLEXIBLE 0 10. RIGID PLASTIC 4647 ❑ 90. NONE ❑ 95. UNKNOWN 99.OTHER ( ): 464c PIFINGfI URBINE CONTAINMENT SUMP TYPE 1. SINGLE WALL ❑ 2 DOUBLE WALL 90. 4644 . . V7,VENT, VAPOR: OVFI��1':AND RISER PIPE;PIPING G011T'RUCTI0N VENT PRIMARY CONTAINMENT . STEEL U 4. FIBERGLASS U 10. RIGID PLASTIC Ll 90. NONE U 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 13 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 46411 VR PRIMARY CONTAINMENT 0 L STEEL 13 4.r RGEASS ❑ 10. RIGID PLASTIC ❑ 90. NONE El 99. OTHER (Specify) 4648 464gi VR SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464b 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL ❑ 90. NONE 4641. RISER PRIMARY CONTAINMENT 0 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 460j 464' 1 -99. RISER SECONDARY CONTAINMENT 0 1. STEEL. 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE ❑ OTHER (Specify) 464k 4641 FILL COMPONENTS INSTALLED 0 1. SPELL BUCKET E3 3. STRIKER PLATFiBOTfOM PROTECTOR C CONTAINMENT SUMP 451ac ' .VII:.#INDEX'D1SMSW .. NTAIN1Vl@1T`fUDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ L DOUBLE WALL ❑ 3. NO DISPENSERS Ekft. NONE 4691 CONSTRUCTION MATERIA!. Q L STEM 0 4 FIBERGLASS 0 10. RIGID PLASTIC ❑ 99. OTHER ( ) 469bc VIII. CORROSION gRO?ECTI©N STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT6. ISOLATION 4Q. EL APPLICANT SIGNATURE . CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored mid that the information provided herein is true, accurate, and i 11 compliance with legal requirements. APPLICANT SIGNATU DATE 470. co•25 •o APPLICANT NAME (print) 471. APPLICANTTtILE 4711 \QvQA(,� I-a>+C Q. UPCF UST -B - 112 Rev. (1212007)