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UNIFIED PROGRAM CONSOLIDATED FORM A�(( J UNDERGROUND STORAGE TANK \V1 I /2.71 OPERATING PERMIT APPLICATION-TANK INFORMATION(one�o m u37) / TYPE OF ACTION (Check one item only. For an UST permanent closure m removal,complete only this section and Sections I,it,111,IV,and IX below) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CRANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SIFE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410' DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) BUsSTSS NAME(Sties FACILITY NAMEor DBA-Doing Business As) 3 /�"iU�lr-rU }fit; -c. 1.-�.-C. !/ 4-. �1� Q_ BUSINESS SITE ADDRESS IID CITY 104 H.TANK DESCRIPTION TANK 11 # �7 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 / O ( D3 I.A STAND-ALONE TANX 2.ONE M A COMPARTMENTED UNIT. DATE UST BYSTEM INSTALLED 43s "'"` �`a.n�"' is Ne wuc �j I TANK CAPS ITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT / 43'1 4-3 III.TANK USE AND CONTENTS TANK USE ❑ Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVLlT10N FUELING 439 I� 3.CHEMICAL PRODUCT STORAGE O 4.HAZARDOUS WASTE Hee W Ue Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHBC§252813(.)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99 OTHER (S ily): 439. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL9.OTHER PETROLEUM S ): O, NON-PETROLEUM;L) 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM 3 i ): 440b IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ci : 444a SECONDARY CONTAINMENT '--� 1.STEEL ❑3.FIBERGLASS ❑6.EffiERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN .OTHERS ): Cyr V' /& use OVERFILL PREVENTION LJ 1.AUDIBLE$VISUAL ALARMS 2.BALL FLOAT U J.FILL IUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99,OTHER 4m SYSTEM TYPE I.PRESSURE ❑ 2.GRAVIrY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 3CCR 02636(aN3) 458 PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 469 ❑ 90.NONE ❑ 95.[JNKNOWN ❑ 99.OTHER(3pecify): 4Ma SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 93.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGrrURBME CONTAINMENT SUMP TYPE 1.SMGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPORRECOVERY(VR},AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464. VENT SECONDARY CONI MN.cpj U L STEEL U 4.FIBERGLASS 0 10-JUGID. PLASTIC 90.NONE 99.OTHER(Spcei ) 464! VR PRIMARY CONTAINMENT U 1.51EEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4690 VR SECONDARY CONTAINMENT U L STEEL U 4.FIBERGLASS ❑ IO.RIGIDPLASTIC4641 90.NONE 99.OTHER(Specify) 4641 VENT PIPING TRANSITION SUMP TYPE Q I.SINGLE WALL 2.DOUBLE WALL 9p. 4641; NONE RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT U L STEEL U 4.FIBERGLASS 0 10.RIGID PLASTIC 41 90.NONE 13 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 133.STRIXER PLATFlBO7TOM PROTECTOR U 4.CONTAINMENTSUMP 4aK VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 02.DOUBLE WALL ❑ 3,NO DISPENSERS 90.NONE 469e CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RICID PLASTIC ❑ 99.OTHER(S i ) 469Rc VIII. CORROSION PROTECTION STEEL COMPONENT PROTEC71ON ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISO[ATION a4s. IX APPLICANT SIGNATURE CERTIFICATION: Ice that this UST system is compatible with the hazardous substance stored and that the information proNded herein U true,accurate, and in fuB com Bance with I al ulremeoh. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 4n. APPLICANT TITLE 4n. UPCF UST-B-1/2 Rev.(12/2007)