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a UNIFIED PROGRAM CONSOLIDATED FORM t430 UNDERGROUND STORAGE TANKOPERATING PERMIT APPLICATION-TANK INFORMATION (One form T) <br /> TYPE OF ACTION (Check one item only. Fora/)STcloslae or removal.complete cult,this section andSecrim,L iL Ill/V andLYbelnw) . <br /> ❑ I.NEW PERMff [j 3.RENEWAL FERMI f ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON STfE 8.UST REMOVAL <br /> DATE.UST PERMANENTLY CLOSED: 41p4 DATE EXISTING UST DISCOVERED: ooh. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) I F1 hC _ - <br /> BUSI:' ME(Same as FaciliyNaine or DBA-Doing B4aine .4s) 3 <br /> I a 46AIA e56r7l <br /> BUST SS SITE.ADDR I'll. CITY IInn, <br /> q,QC 4 L' <br /> II. TANK D SCRIPTION <br /> TANK ID 0 43=. TANK MANUFACTURER 433. T6,NK CONFIGURATION:THIS TANK IS 434 <br /> 1.A STAND-ALONE TANK Compla<om pap:f9r,1.. <br /> C- ) 2.ONE INA COMPARTMENTED UNIT ranpanoml in the unit. <br /> 11 <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. 1 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 3 -�,'LCr ;C <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING I�4'-I6.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Izluda Used at) Q 5.EMERGENCY GENERATOR FUEL IHSC¢SBLBd] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 93.UNKNOWN Q 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED Ic.MIDGRADE UNLEADED ❑ Ib.PKEMIUMUNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM(Specify); 446a <br /> NON-PETROLEUM: 7.USED OIL 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. <br /> IV. TANK CONSTRUCTION <br /> _TYPE OF TANK ❑ LSINGLE WALL Q"!_DOUBLE WALL [3 95.UNKNOWN_ 443. <br /> PRIMARY CONTAINMENT -e'C STEEL Q 3.FIBERGLASS [36.INTERNAL BLADDER____ u4. <br /> _____ E3 7.STEEL INTERNAL LtNINO ❑ 95.UNKNOWN ❑ 99.OTHER(Specif L 444.$E <br /> _. _._COND.4RY CONTAINMENT [i'I.STEEL ®;i FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER C3 __7.JACKETED �ddS <br /> Q 90,NONE 095.UNKNOWN O 99_OTHER(SEeci ): 44U <br /> OVERFlLL PREVENTION ❑ LAUDIBLE&.VISUAL ALARMS & BALI FLOAT ;,FILL TUBE SHUT-OFF VALVE 40. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODU T/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION LSINGLE WALL _2_DOUBLE WALL 99.OTHER <br /> 60. <br /> SYSTEM TYPE ).PRESSURE GRAVITY <br /> �] 2. Q 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION <br /> LASTIC 1CCR¢263ty47(3�__458. <br /> PRIMARY CONTAINMENT .STEEL 4.FIBERGLASS Q 8.FLEXIBLE <br /> Q 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE _ ❑ ns.un'K_n_owN ❑ 99 <br /> __OTNER(Spciy): 46a, <br /> SECONDARY CONTAINMENT ❑ I.STEEL �4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. <br /> _ (d'90.:NONE_ _ [3 95_INKNOWN _ ❑ 99_OTHER(5peciy): 464c <br /> P[PING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL 0 2.DOUBLE WALL 90.NONE 4644. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT R`I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE Q 99.OTHER(Specify): 464ei <br /> VENT SECONDARY CONTAINMENT [3'i.STEEL Q 4.FIBERGLASS Q 10.RIGID PLASTIC ❑ 90.NONE 464E <br /> Q 99.OTHEA(Specify): 46a0 <br /> VR PRIMARY CONTAINMENT EY-1.STEEL [3, 4. ❑ 10.RIGID PLASTIC C3 90.NONE Q 99.OTHER(Specify): yam¢ <br /> VR SECONDARY CONTAINMENT _O LSTEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q NONE 4 n <br /> _ ❑ 99.OTHER(Specify): 464hh <br /> __ <br /> VENT PIPING TRANSITION SUMP TYPE 2M.SINGLE WALL Q2.DOUBLE WALL 90.NONE 4 <br /> RISER PRIMARY CONTAINMENT Q'I.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑RO.NONE ❑ 99.OTHER(Speeiy): y4M60.f <br /> RISER SECONDARY CONTAINMENT ❑ I:STEEL ❑ 4.FIBERGLASS Q I O.RIGIDPLASTIC '90.NONE ❑99.OTHER(Specify): 464kL <br /> FELL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATFJBOTTOM PROTECTOR 4.COhTA1NMENT SUMP <br /> 4 Irc <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> _CONSTRUCTION TYPE 1.SINGLE WALL .._ DOUBLE WA_LL___ S 90.NONE <br /> 3.NO DISPENSER469a <br /> CONSTRUCTION MATERIAL .STEEt �- <br /> Q d.FIBERGLASS ❑ 10.R[GID PLASTIC Q 99.OTHER(Spent,) 40b <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ET 2.SACRIFICIAL ANODES 4.IMPRESSED CURRENT 0 6.ISOLATION i+8 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 c st [ 's stem is compatible with the hazardous substance stored and that the information provided herein is tree, <br /> ac rate a in no utrice with le al recrairements. <br /> APPLICANT SIGNATUR DATE -_ /Z 470 <br /> APPLICANT NAME(print /1 -DA6; - Y3 APPLICANT TITLE -) _ 477. <br /> UPCF UST-B Rev.(12/2007)-1/2 www.uaidccs.org <br />