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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 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 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE Ej 7.UST PERMANENT CLOSURE ON SITE D L UST REMOVAL DATE UST PERMANENTLY CLOSED: 4 DATE EXISTING UST DISCOVERED: 43M L FACILITY INFORMATION FACILITY IDA(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 Circle K Store 2701205 BUSINESS SITE ADDRESS 103 CITY 1a 16470 Cambridge fa0uo II.TANK DESCRIPTION TANK IDA 01 432 TANK MANUFACTURER 433 TANKCONFIGURATION: THISTANKIS 434 Xerxes ®1.A STAND-ALONE TANK ❑ 2.ONE W A COMPARTMENTED UNIT. C lege one PMc(bree'h alba uch. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 112/98 11,849 One DI,TANK USE AND CONTENTS TANK USE IS la.MOTOR VEHICLE FUELING G 16.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTEInclude th4OJ5. ( ) ❑ 99.OTHEMERGENCY (Spa GENERATOR FUELIHSC 5252115(dl ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify)! 439. CONTENTS PETROLEUM: N la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADm ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL 0 5.JET FUEL ❑ 6.AVIATION GAS O 8.PETROLEUM BLEND FUFl ❑ 9.OTHER PE7ROLEl1M (Specify): ao NON-PETROLEUM: 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): a4ob IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINO USLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRARY CONTAINMENT 1.STEEL ® 3.FIBERGLASS LJ 6.INTERNAL BLADDER 44d ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER ( eci ); 444, SECONDARY CONTAINMENT ❑ I.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LR4F3t ❑ 7.JACKETED us 90.NONE [395.UNKNOWN C399.OTHER (5 i ): 445, OVERFILL PREVENTION I.AUD®LE&VISUALADRMS 2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 171 LSINGLE.WALLED 192.DOUBLE-WALLED [199.OTHER mo SYSTEM TYPE N L PRESSURE ❑ 2.GRAVITY [3 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION IM CCR 626%(.X3)] 451 PRIMARY CONTAINMENT 0 I.STEEL 29 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 9 ❑ 95.UNKNOWN ❑ 99.OTHER(Spedry): 464. SECONDARY CONTAINMENT 1.24M ® 4.FIBERGLASS E3 8.FLEXIBLE 0 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL 90,NONE 4646 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL,PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.IIIGiD PLASTIC 90.NONE 0 99.OTHER(Specify) 464' VENT SECONDARY CONTAfNMINT IJ 1.STEEL ❑ q,FIBEIlG1AS513 10.RIGID PLASTIC ® 90,NONE 0 99.OTHER(Specify) 4Mf VR PRIMARY CONTAINMENTLJ 1.STEEL 19 4,FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Speily) 464, 4M,l VR SECONDARY CONTAINMENT D L STEEL El 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99,OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 464h1 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.GTHER(Speciry) 464i 464'1 RISER SECONDARY CONTAINMENT13 1.STEEL, 10 4.FIBERGLASS 10.RIGID PLASTIC Ll 90.NONE Ej 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET ® 3.STRIKER PIATEH50TTOM PROTECTOR 46461 ❑ 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGIE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL 1.STEEL C1 4.FIBERGLASS 10.RIGID PLASTIC R 4696c VDI, CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) O 4.IMPRESSED CURRENT 09 5.ISOLATION 496. DL APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system Is compatible with the hasardous substance stored and that the Information provided herein Is true,accurate, and in full compliance with legal r uirem ts. APPLICANT SIGNATURE DATE 11/7/08 476. APPWCANT NAME(ptinQ RICKCiOSS@It J11' APPLICANT TITLE Ef)VIfODrDerltel Compliance Manager 471 1 UPCF UST-B-112 Rev.(I2f2B07)