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Dec 05 11 05: 22p - p. 5 UNHUD PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(onc roan per UST) TYPE OF ACTION (Ch,*one it®only. Form USTpermnumt ctosu a arnmowa.complete only this section and Sections L H,m,1V,and U below) _ ❑ I,NEW pERMIT ❑ 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SFCE EJ S.USTREMOVAL DATE UST PERMANENTLY CLASSED: moa DATE EmsTING UST DisCOVERID: 43% I `Tv1CI�tTs'lP7IY9RiYI�1TdON ;. a. 77 .7777777 FACILITY ID p(Agency Use 6Wy) ` 4+ 1 BUS29ESS NAME(Same ac FACILITY NAME orDEA•Vaiox Busims As) BUS0 SSITEADARFsh`�.S �n Wa lot S'EUC�kar CA- to IC:TANKDESCRTPI ION ['' TANK IDq 432 TANK MANUFACTURER 433 TAM CONFIGURA71O.Y:TIB8 TANK IS OO rX-Q � NALONET 37o�o7J67 2ONEINACOMAR11,0 TIDUNT. QC mY COfOfL el WEtmIL DATE UST SYSTEM INSTALLED 435 TANK CAPACTIY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 .::•'..•.; .. r s, ., .:IQ:':i3'ANK'LLSE'.A31'DCONTENTS - _... . TANK USE 15 1.MOTOR VELHCLEPUELING Q ib.MARIINAF'UOLING ❑ Ia.AVLATIDNFUELING Q 3.CE3EMiCAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE Q dr U44 W) Q5.EMBROENCYOENEiLATOR FUEL 9W PWL%.B Q 6.OTHER GENERATOR FUEL Q 95.UNKNOWN Q 99.OTHER ): 43% CONTENTS PETROLEUM: ® Is.REGULAR UNLEADED 0 Ia M)DORADEUMF.ADED Q 1b.PREMIUM UNLEADED 490 0 3.DIFSEL ❑ S.JETFUEL Q&AVIATION GAS Q &PETROLEUM BLEND FUEL Q 9.OTHERPMOLEUM 44(¢ NON-PETROLEUM:Q 7.USED OM Q 10.ETHANOL I LOTH R NON-PETROLEUM - 460e •, TYPEOFTANK 1.SINGLE WALL . 2.DOl/BLE WALL 93.IIATNOWN 993 PRIMARY COTTADIMENT ) I.STFEL IS 3.FtBERGLASS Q 6.11ffFRNALBLADDER 999 Q ?.STEEL+INIMNAL LINING 095.UNKNOWN 0 99.OTHER SECONDARYCONTAINNFM i.STEEL .FIBERGLASS &PXIENORMSMBRANELFNFR 7.lACKEIED 945 ❑ 90.NONE 95.IJERG= 99.OliR•7t )- Mss OVERFILL PREVENTION I.AUDIBLE d VISUAL ALAAMS 2.RG4117AAT 3.FBI TUBE SHUT-OFF VALVE 04.TANKMEETSRE UTREbENIB'FOR EXEMPTION FROM OVERFILL PREVENTIONEQUIPMENT 77,;. Y-'PRODUCrAWAStEPIPING,GUNSMUCM[ON -, „ PRINGCONSTRUCIION ❑1.SA'GLE-WALLED ZDOUBIE-WALLED UW-OTHER SYSTEM TYPE ® 1,PRESSURE LGRAVITY W 3.CONVENTIONAL SUCTION Q 4.SAFESUCTTON.3CCR PRIMARY CONTAINMENT El 1.STEEL 4.FIBERGLASS LI S.FLEXIBLE 0 l0.RIGIDPIAsric 464 Q 90.NONE ❑ 95.UNKNOWN Q 99.0THER(S ): 4W SPCONDARY ODNTA94MENT ❑ 1,STEEL 4.1IBERGLASS 8.FLEXIBLE Q In.RIGID PLASTIC 9646 Q 90.NONE 195.UNKNOWN Q 99.O77M }: 96k PIPINGfr(JRE4ECAKTATNMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLEWALL 0 90.NONE 464d I 33 VENT'kAPOR RECO jg2t=lt) AIVD RL�ER/,EXT T PIPE PIPIl�GfOIYSTRIICTLON VENT PRIMARY COMAIINMETTC I.STEII. 4.FIBERGLASS Io.R1OIDPLASTIC 90.N01 99.OTHER(Spedfj•) 464e 4 el VINS SECONDARY CONTAINMENT - 0 LSTEEL E3 4.11BERGLASS 0 10.1UGIDPLAS7IC 90,3ONE 99.OTHER(Sprc4) 4Nf x690 VR PRIMARY CONTAINMENT Q 1.STEEL Q 4.FIBERGLASS 0 10.RIGID PLASTIC 1A 90.NONE ) 99.OTHER(SPwi(v) 4w 8 VR SECONDARYCONTALNMENT 1.STEEL 4.FIBERGLASS 10.R1GIDPLASnC 90.NONE 99.OTHER(Speeify) 46W 466" NEPA PIPING TRANSITION SUMP TYPE 0 !.SINGLE WALL 0 7DOUBLE WALL 1Z 90.NONE 464, f RISER PRIMARY CONTAINMENT 1.STEEL U C FBERGIASS LJ10,RIGID PLASTICU 90.NOISE I r99. 464i 461'1 2�LCnO!N NDARYCONTA94MENT LSTFEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 199.OTHER(Splfy) 461k 46 k] NNSIALI.ED 1.SPBL BIR7SE1' 3.STRIKPR PL0.7F1BOTIOM PROTECTOR 4.COMAINh/EN'TSUMP 431aK .'LIt1DER'DWENSEiE`CO]VTAI1V1V1CN',C.(�S m" PE 1.SINGLE WALL Q 2.DOUBLE WALL 'I NOD)SPENSERS Q 90.NONE 469• 'TNALI:STEEL.. 4.FBERLASS IO.RIGIDPLASTIC 99.p7'fim(S )�L;'.COItROSION;PItOTECTION STTEELCOPROTECLION 02-SACRIFIOALANDDE(S) Q 4.IMPRESSED CURRENT 6.LSOLA7TON a4L IX APPLICANTSIGNAURE. ' CERTWICATION:T..tW tBat this UST"stem b,coral fibl.xMh the hazardous substance stored and that the bfasm:tlon provided herein is true,accurst.. and In full m Hance with legal re uiremeuts. APPLICANT SIGNATURE i 2 -`O,Lp'T DATE APPLICANT NAME(print) SiJj'!N ltJ�rtr�, 'jl S��✓G/'! 47'- L AI'PucANr 1 v i./NEf UPCF UST-B-112 Rev.(12/2BW7)