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UNIFIED PROGRAM CONSOLIDATED FORM / UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATIVIF (Zor rm per UST) i'YPF.OF ACTION (Check one item on/v. Para(LST closure or removal,complete only this section and.SecHmcs 1,l[w.IV,and 1X below) nn ❑ I.NP:W PERMTI' 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION / EIVIPORAR Y USi Ci..OSURF 7.UST PERMANENTCLOSURE:ON SITE S.UST REMOVAL. `Le DAT(:1151'PERMANFNTI.Y CLOSED4?•,4 1 DATE EXISTING I IST DISCOVI?RIiD- fmn L FACILITY INFORMATION FACILI'T'Y ID M(Ageny Use Only) r BUSINESS NAME(Same as Facility Name or ORA /Xing Business As/ 5 M Ir* BUSINESS SITE ADDRESS 1111. CITY w II. TANK DESCRIPTION TANK ID W 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS'I'ANK IS 434 �I.A STAND-ALONETANK C..gava.Pekel.,e DS ) r V ❑ 2.ONE INA COMPARTMENTED UNIT cane nainn me-,, DATE.US SYSTEM INSTALLED 415 TANK CAPACI'T'Y IN GALLONS 4W, NUMBER OF COMPARTMENTS IN'I'EIE UNIT 4n 3 I I opo III. TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING R Ib.MARINA FUELING 0 Ic.AVIATION FUELING 43�+ 03.CHEMICAL PRODUCT STORAGE: 04.HAZARDOUS WAS'fF(NdWes asedoi) 05.EMERGENCY GENEiRA"TOR FUEL gu2rl_5(01 0 b OTHER GENERATOR FUEL. ❑ 95 UNKNOWN 0 W.OTHER(SP ify): 4s�a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED R Ic.MIDGRADFaINLF:ADED ❑ Ib.PREMIUM UNLEADED -lib ❑ 3.DIFSEI. 0 5.JFT FUEL ❑ 6.AVIATION GAS ❑ R.FF'E-ROLEUM BEEN)FUEL 0 9.OTHER PFTROLELIM(Specify): 4aa NON.PETROLEUM:❑ 7IISEDOII. 0 10.ETHANOL ❑ 11,OTHER NON-PFTROLFUM(S ): +uib. IV. TANK CONSTRUCTION TYPE OF TANK 01.SINGLE WALT. $12.DOABLE WALT. 095.UNKNOWN 4m PRIMARYCONTAINMENT ® I.STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4w 0 7,STEEL 1 INTERNAL LINING ❑ 95,UNKNOWN 0 W.0TI IER(Spceify): aaa SECONDARY CONTAINMENT a I.SI-F;EL J&3.FIBERGLASS 0 b.EXTERIOR MEMBRANE:LINER 0 7.JACKETrD 445 0 9m.NONE (:1 95.UNKNOWN ❑`N.O'rHER(Speciryy 4asa OVERFILL PREVENTION 0 I.A(1DIBLF.AVISUALALARMS K2.BALLFLOAT 143.FILL TUBE SHUT-OFF VALVE 452. 0 4.'TANK MEETS REQIIIREMENIN FOR EXF.MPI"ION FROM OVERFILL,PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION J4 I.SINGLE WALL PZ 2.DOUHI L WALT. ❑ W.O'THFR 4W SYSTEM TYPE DR I.PRESSURE ❑ 2.GRAVITY 0 3,CONVENTIONAL SUCTION 04.SAFE SUCTION 123 CCR 0263 9)3)1 41. PRIMARY CONTAINMENT B I.STEEL. )n 4.FIBERGLASS 0 S.FLEXIBLE 0 I0.RIGID PLASTIC ul ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.0 ILER(Spod ffy): 461a SECONDARY CONTAINMENT ❑ I.STFEI, C9 4.FIBERGLASS ❑ R.FLEXIBLE 0 10.RIGID PLASTIC 46th ,&%,NONE 095.UNKNOWN 099.(rn wit(spiry): 46+c PIPING/TURBINE CONTAINMENT SUMP TYPE & L SINGLE WALT. ❑ 2.DOUBLE WALT. 0 W.NONE uwc VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT fia LS'I'ELL 0 4.FIBERGLASS 0 Io.RIGID PLASTIC ❑ 90.NONE 0 W.01'14ER(Specify), 44�k VENT SECONDARY CONTAINMENT 5d LSTREL 04.FIBERGLASS 010.RIGID PLAFI'IC ❑ 90.NONE 0 W.01 HER(Speeify): wr VR PRIMARY CONTAINMENT ja I.STEP:L 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [3 " urHER(S xcify,): uay VR SECONDARY CONTAINMENT tR I.S'TFF.L ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ W,OTHER(Specify). 461h .,f x Ohl VENT PIPING TRANSITION SUMP TYPE ®.I SINGLE.WALT. ❑ 2.DCNIBLE WALT. {g W.NONE RISER PRIMARY CONTAINMEN I DLI SIM. 0 4 1115ERGLASS ❑ Io.RIGID PLASTIC ❑ W NONE.. 0 W OTHER(Specify) 41� RISER SECONDARY CONTAINMENT ❑ 1 s TFFI 0 4 FIBERGLASS ❑ 10.RIGID PLASTIC 19 90.NONE ❑ W.OTHER(Spvejt ) J1I' i F11.1.CUMPUNIINTS INSfALLISU --� I.SPILL RCK'KEiT K; SI RIK[R PLAIT/fN)'PI"GM PROfI t TOR -- 0 4 CONTAIN MFNf FUM(' VII. UNDER DISPENSER CONTAINMEN'I'(UDC) N IYI'P JRL1 Cti(IIPW1ll ❑ , rx'I!Ip\r nl. �'"IYn i. -. . -- _- - I41NYIR11"THIN M4 Ii RIA( �(+ �n bl ❑ 1_F1HHiNl r[v ❑ In Klt%ID ui sifi( ❑ 'r �;!IER �Ia..... �nII r R _O I N PP-0 rFf' >fn!KJ ssa .: an. Att LIC:A;ti i Sii,iv rl k tjAL f ne e. ♦ � •, a _. f a e eell tie Lei _ex.�s♦ ae G.�ee iue a ,e..n.ee eae 1• a•.0 •ie� ,. ,.u_