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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For.an YST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430e DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY ME or DBA-Doing Business As) 3 oc /Z,oS AlCTn1ERSH'19 JrN�c- DSA JeE's TRAVEL P✓,�z/� BUSINESS SITE ADDRESS5t AR�AN no II. 103 CITY / � 1 'rLl f10p t 104 !l `.TANK DESCRIPTION , 1� 1 TANKID4 432 TANK MANUFACTURER 433 T.nN�.A9NFIGURATION: THISTANKIS 434 -r.A04;08 MbDEa^' W��(P + ❑2,INEAIN COMPPAARTANK TMENTEDUNIT. Com late ane Pacefor each come tin the wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GA LONS 436 NUMBER OF COMPARTMENTS IN THE UNIT + 432 I" III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE fc,ludea Used Oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§252x1.5(.)1 ❑ 6.OTHERGENERAT FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b TANK CONSTRUCTION TYPE OF TANK El 1.SINGLE WALL 2. QUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL EV1.yfBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL,INTERNAL NING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 5je3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS eci 443a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452. ❑ 4.T.ANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFIL PREVENTION EQUIPMENT V. .PRODUCT 'WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1 SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEMTYPE .PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)3)I 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ E STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 1..UNKNOWN [199.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP'fYPE SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPO RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT V1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 49:1 46,10 VENT SECONDARY CONTAINMENT LSTEEL ❑ FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464f1 VR PRIMARY CONTAINMENT ❑ LSTEEL FIBERGLASS El 10.RIGID PLASTIC D 90.NONE ❑ 99.OTHER(Specify) 4648 64 1 VR SECONDARY CONTAINMENT LJL EL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9 .NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ .SINGLE W 2.DOUBLE ALL WALL 90.NONE ab4i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 0.NONE ❑ 99.OTHER(Specify) 4641 641 RISER SECONDARY CONTAINMENT ❑ 1. TEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.IN ❑ 99.OTHER(Specify) 464k 4mk1 FILL COMPONENTS INSTALLED L SPILL BUCKET ❑ 3.STRIKER PLATETIOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2 UBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL El4.FIBERGLASS 0.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full c lia Ace WitVftal requirements. APPLICANT SIGNATURE DATE 'o 0 420. APPLICANT NAME(print) � d 1. APPLICANT TITLE 422. UPCF UST-B-1/2 r Rev.(12/2007) li.