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i a c t4 W' c�i 4��r�c�`(� d�io-U UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one Tort,per ust) TYPE OF ACTION (Check one item only. Foran UST permmmt closure or removal,mmpWe colt'this Section and Section I,II,TB,IV,and D(below) 4" ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ll CHANGE OF INFORMATION n-d-ITD�� .TEMPORARY UST CLOSURE El 7.UST PERMANENT'CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: " DATE EXISTING UST DISCOVERED: '30b L FACILITY INFORMATION FACILITY ID N(Ageol Use Only) -1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Businns As) I BUSINESS SITE ADDRESS I03 CTY �a II.TANK DESCRIPTION TANK ID 432 TANK MANUFACTURER 433 TANK CONFIGURAnOM THIS TANK IS 4J4 ^ � ❑I.ASTAND-MANE TANK p V•Sl l��( ONE IN A COMPARTMENItD UMI. DATE LIST(SYSTEM INSTALLED 435 T C ACHY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 431 III TANK USEAND CONTENTS TANK USE I a MO TOR VEHICLE FUELING ❑ Ib.MARINA FUELING [3 1.AVIATION FUELING 439 J.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(iriutla Ued 0) ❑ 5.EMERGENCY GENERATOR FUEL IraO 4LIISIS(cH ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OIIIER(S } 4J CONTENTS PLTROLEUM: ❑ Is REGULAR UNLEADED ❑ Iva MIDGRADE UNLEADED b.PREMIUM UNLEADED 4aa ❑ 3.DIESEL ❑ 5.iET FUEL 0 6.AVIATION GAS ❑ 8.PETROLEUMUSEDOIBLEND FUEL ❑ 9.OTHER PETROLEUM F34t) NON-PETROLEUM: 7. . ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 44ae IV. TANKCONSTRUCIION TYPG OF TANK ❑ I.SINGLEWALL 2-DOUBLEWALL -95.1TNKNOWN 44l PRDAARY CAQ immENT ❑ 1.STEEL LJ J.FIBERGLASS U 6.INTERNAL BLADDER 444 ❑ 7.STEEL«rNTERNALLLNING O95.UNKNOWN 99.OTHER (S ): w4. SECONDARY CONTAINMENT El I!STEEL, CO.FIBERGLASS ❑ 6..TTFRIOR MEMBRANE LUTA ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNIONOWN ❑99.OTHER 5 w5. OVERFBI PREVENTION IN BLE I VISUAL ALARMS 2Rdr, FLOAT 3.FILL TUBE SHUT-OFF VALVE 4R ❑ 4.TANK MEETS REQUIREmENB FUR EXEMPUON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT./WASTE PERNG CONSTRucnoN, - PIPMG CONSTRUCTION ❑1.SINGLE-WALLED DOUBEF-WALED ❑99.OTHER 460 SYSTEM TYPE L PK,, URE U 2.GRAYTTY U 3.CONVENTIONAL SUCTION ff4.SAFE SUCTIONP LCR F2fiW XD 458 PRIMARY CONTAINMENT 1.STEE, 4.FIBERGLASS u 8l U 10.RIGm PLASTIC 4M ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTIMFR(S9ccifyl: 464 SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS E, LFIEXIBLE 10.RIG.PLASTIC 4646 Q 90.NONE U 95.UNKNOWN ❑ 99.OTHER( ): 464 PIPING/MRBINECONTAINMFNT SUMPTYPE U 1.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 461E VI:.VENT, VAPOR RECOVERY(VR)AND RISER/FELL PIP.EPIYING�CONSIRIICTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIG.PLASTIC 90.NONE 99.OTHER(Sill 464 VENT SECONDARY CONTAINMENT 1.STEEL ,FIBERGLASS !0.RIGm PLASTIC 90.NONE 99.OTHER 46TH lSPmb) 464r VR PRIMARY CONTAINMENT' 46'n 1.STEEL 9.FIBERGLASS 10.RIGm PLASTIC 90.NONE 99.OTHER(Spll 461r VR SECONDARY CONTAINMENT LSTEII. .FIBERGIASS 10.Il PLASTIC 90.NONE 99.OfFIBR($pcJry) 464Y VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WAf.L iDOUBLE WALL 90.NONE MITI RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS 0 10.RIG.PIASI'IC 90.NONE 99.DIETER(SP_fy) 4641 RISER SECONDARY CONTAINMENT u 1.STEEL Lj 4.FIBERGLASS5 I0.RIOm PLASTICU 90.NONE U 99.0TIMER(Sp4s;fy) 4 4k FILLCOMPONENTS INSTAf.LEp 1.SPILL BUCKET 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENTSIIMP 43I VII.UNDER DISPENSER'CONTAINMENT.(VDC).. 1. CONSTRUCTION TYPE I.SINGLE WALL ❑2 DOUBLE WALL U J.NO DISPENSERS ❑ 90,NONE 46'h CONSTRUCTION MATERW, .STEEL U 4.F.ERGLASS10.RIGID PLASTIC ❑ 99.OTHER(Spel a696c VIII. CORROSIONPROTECITON STEEL COMPONENT pROTECHON ❑ 7 SACRIFICW.ANODE(S) ❑4.IMPRESSED CURRENT ❑ 6.ISOLATION 446. IX. APPLICANT SIGNATURE CERTIFICATION: I cerdfy that this UST system is wmpadble with the haardoes nMtaxe torrid and tbat the hrfor nm tion provided herein is true,accaul and]--,.--am Iiauce wph I d uiremeots. APPLICANT SIGNATURE /DATE J 4'ro. APPLICANT NAME(print) 4T1' APPLICAM'TITLE ,n,^, 4n ,,l �9c Gy1 UPCF UST_B-1/2 .. R".(l2nM7)