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Az- UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(ow romt per UST) TYPE OF ACTION (Check one item only. For an UST pa mt closure or removal,mmplcee only this tion and Sections L IL Ill,TV,and IXbelow^- 490 ❑ I.NEW PERMrr El 3.RENEWAL PERMIT .CHANGE OF INFORMATION c7L-LJc-fw z2 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.USC REMOVAL DATE UST PERMANENTLY CLOSED: 41 1 DATE EXISTING UST DISCOVERED. I. FACMITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Seine as FACILITY NAME or DBA-Doing Busirss As) 3 0bf4!'S L.l 'i�cz 072 BUSINESS SITE ADDRESS IID CITY t.. cr� L1n�evoll�e LA_ IL TANK DESCRIPTION` TANK ID M 433 TANK MANUFACTURER 433 TANK CONFIGURATION:71US TANK IS 4N .1 9L A STAND-AIANETANK �r1514-sin\iu 2.ONS IN A COMPARTMENTED UNIT. DATE UST SYSTEM INSTALLED 435 TAM; ACI Y IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNrr °D UDL TANK USE AND CONTENTS TANK USEIs.MGfORVEHICLE FUELING ❑ Ib.MARINA FUELING Ll I.AVIATIONFUELTNG 439 3.CHQMIULPRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE(btlide llwd 010 05.EMERGENCY GENERATOR FUEL(iSC¢431A.)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER ): 439' CONTENTS PETROLEUM: .- 1a REGULAR UNLEADED [jIa MMGRADE UNLEADED ❑ Lb.PREMIUM UNLEADED 140 S.DIESEL ❑ S.1ET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S °40e NON.PETROLEUM:Ll 7.USED Oa. ❑ 10.ETHANOL I I.OTHER NON-PETROLEUM 44aa rV. TANKCONSTRUCPION TYPE OF TANK- I.SINGLE WALL .Mfl DOUBLE WALL95.UNKNOWN N3 PRIMARY CONTAINMENT Cl 1.STEEL Ll 3.FIBERGLASS 6.INTFRNAL BLADDER 414 ❑ 7.STEEL♦INTERNAL LINING ❑ 9s.UNKNOWN ❑ 99.OTHER (S t7n SECONDARY CONTAINMENT ❑ 1.STEEL �IMERGLASS ❑ 6.EXTERIOR MEMBRANE(.WER 7.JACKETED 145 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER ): 165° OVERFILLPREVENTION I.AUDIBLE k VISUAL ALARMS 28AIl F1DAT 3.FILL Tl1BE SHUT-OFF VALVE 432 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERF1Il PREVENTION EQU@MEM V. PRODUCT%.WASTE PIPING CONSTRUCTION, - - PIPING CONSfRUCT1ON OLSINGLE-WALLED DOUBLE-WALLED 099.0THER. 460 SYSTEM TYPE K I.PRESSURE ❑ ZGRAVITY Q 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION rM CCR fXWs)P)I 4A PRIMARY CONTAINMENT U 1.STEEL4.FIBERGLASS a. CIB FLELE 10.RIGID PLASTIC 464 ❑ 90.NONE •�95.UNKNOWN ❑ 99.OTfIFJt(Specify): . 464° SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS a.FLEXBLE LI 10.RIGID PLASTIC 4616 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.QTFIR(Sp¢Ry): 164' PIPMGMI"INE CONTAINMENT SUMP TYPE I.SINGLE WALL 2MLEEWALL 0 90.NONE 46M VL VENT,VAPOR RECOVERY(VR)AND RISERI FII-L PIPEPIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE U W.OTHPA(Spmfy) 161^ 464e1 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.GTFIDt(Spediy) 4641 4411 VR PRIMARY CONTAINMENT CI 1.STEEL 4.FIBERGLASS 0 10.RiGm PLASTIC 90.NONE U 99.OTHER(Specify) 464, VR SECONDARY CONTAINMENT 0 ].STEEL 4.FIBERGLASS 0 I0.RIGID PLASTTC 0 90.NONE 0 99.GIHM(Specify) 46W 4681 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS U 10.RIGID PLASTIC Lj W.NONE U 99.CIFHER(Specify) 4611 464'1 RI5ER SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS 0 10.RIGm PLASTIC 0 90.NONE 0 99.0THER(Spe ify) N64k 4l FILL COMPONENTS INSTALLED & 1.SPILL BUCKET El 3.STRIKER PLATEMOTTOM PROTECTOR L3 4.CONTANMENT SUMP 01. VII.UNDER DISPENSERCONTAINMENT:(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE ws CONSURUCOON MATERIAL 1.STEEL ❑ 4.FBERGIASS ❑ l0.RIOm PLASTIC ❑ 99.OTHER(specify) 469ec VDI. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(Sl ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 4q. IX APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the haTardoos substance stored and that The Informstion provided herein is Ime,accurate, and in MB eon Bance with legal mquimnlintL APPLICANT SIGNATU DATE APPLICANT NAME(print) °71' APPLICANT TrILE °R UPCF UST.B-IR Rev.(171200'1)