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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK FX OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per uST) TYPE OF ACTION (Check one item only. Fora UST closure or removal,complete only ihia section and Sectlorrr 1,u M IV and lX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b. FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Businass As) 3. lev.A *040 BUSINESS SITE ADDRESS lm. CITY / _ 1 1 0 �.�.'�" i'o ' l V^T Leo TANK ID# 432. TANK MANUFACTURER 433- TANKCONFIGURATION:THLSTANKIS 434, �- 5r7rjGY� TrJSGo IN 1.ASTAND-ALONE TANK Caoplaeomwaeannm 171 2.0NEINA COMPARTMENMUNIT oompmawn Wia. DATE UST SYSTEM INSTALLED 41S• TANK CAPACIT�YJINJ�GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT an. TANK USE Zi Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ to AVIATIONFUELING 419. ❑ 3.CHEhDCAL PRODUCT STORAGE IJ 4.HAZARDOUS WASTE OaAodm Und din ❑ 5.EMERGENCY GENERATOR FUEL(HaC§252d13I4)1 13 6.OTHIRGENERATORFUEL ❑ 95.UNKNOWN (3 99.01HER(SpWHY); 439L CONTENTS PETROLEUM: a REGULAR UNLEADED [] I.MIDGRADEUNLEADED [Ilb.PRII,GUMUNLEADED A40. 3.DIESEL ❑ 5.JET FUEL ❑ 6•AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL O 9.OT'HER PETROLEUM(Specify):_ 490e. .. _.._ .. NON-PETROLEUM: 7.USED OIL �10.ETHANOL 11.O HER NON-PETROLEUM S eci 440b. i i TYPE OF TANK ❑ I.SINGLE WALL ® 2.DOUBI.F.WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ®,1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7,STEEL+INTERNAL LINING ❑ 95.UNKNOWN p 99.OTHER(Specify): 444% j SECONDARY CONTAINMENT ❑ 1.STEEL M,3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN99.OTIdBR S 44sa OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT - 3.FILL TUBE SHUT-OFF VALVE 452 4.TANK METS RE TS FOR J3 MMFTION FROM OVERFILL PREVENTION EQUUMM PIPING CONSTRUCTION ❑ 1.SINGLE WALL IS 2.DOABLE WALL ❑ 99.OTHER 4% SYSTEM TYPE &1.PRESSURE _❑ 2.ORAVITY 0_ 3.CONVENTIONAL SUCTION ❑ 4-SAFE SUCTION CCR e 3 4%. PRIMARY CONTAINMENT El STEEL 9 4.FIBERGLASS [39,FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S2!Lify): 4"a. SECONDARY CONTAINMENT ❑ 1.STEEL al 4,FIBERGLASS ❑ &FLEMLE 0 10.RIGID PLASTIC 4646. ❑ 90.NONE _❑ 95 UNKNOWN ❑ 99 OTHER(Specify): 4640. ____ .._......._ .._.___ PII ING/TVRDINC CONTARNMEN'I'SU[v[P TYPE, 1.SLVG],G WAi,L ❑ 2.DOUBLE WALL ❑ 90.NONE 464x. VENT PRIMARY CONTAINMENT I.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spooify): 46441. , ._. _._.__..._ 43Tf VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4640 VR PRIMARY CONTAINMENT ❑ L STEEL 99 4.FIBERGLASS [3 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify): 464& 1. VR SECONDARY CONTAINMENT C31.STEEL ❑ 4.FIBERGLASS E310.RIGIDPLASTIC [390.NONE [399.OTHER(Spacify): 4 46/h1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [32.DOUBLE WALL [190.NONE RISER PRIMARY CONTAINMENT ElST 1. EEL Q a.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 961).464'1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.O HER(Specify): _ ,46,)4 -.._.__.-_...__.___ _____.. ____....__..._.__- 1. FILLCOMPONENTSI.NSTALLED �L.1.SPILLBUCKET IN 3.STRIKER PLATWIII MPROTECTOR ❑ 4.CONTAINMENT T.SUMP 4551., all CONSTRUCTION TYPE _ )_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NCNF, 4694. CONSTRUCTION MATERIAL �1.STEEL ❑ 4.FIBERGLASS ❑ 10. UGIDPLASTIC ❑ 99.OTHER(Specify) 469b. STEN.COMPONENTPROTECTION� ❑ ?.SACRIPIC[AL[v\ODfi(S) ❑ 4.IMPRESSED CURRENT [3 6.ISOLATION els MIR 'In I CERTIFICATION: 1 certify that this LIST system is compatible with the hazardous substance stored and that the Informafion 1rovided herein is true, accursde'allEfullcoutme with legal requirements. e' APPLICANT SIGNATURE DATE r/® /3' / - 406. APPLICANT NA (prmt) / h,.,,D a 4n. APPLICANT TITLE /�' aTx ME UPCF UST-B Rev.(12)2007)-12 www.u0idoce.ora