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Co � go 5, 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK Mmu n OPERATING PERMIT APPLICATION- TANK INFORMATION (One 57) iG U - PE OF ACTION (Check one item only. Foe.m UST permanent closure or removal, complete only this section and Sectional, U, III, IV, and IXbe,(ow) 430 ❑, 1. NEW PERMR 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL FFFJJY"" DATE UST PERMANENTLY CLOSED: 12-01-1.3 4Jpi DATE EXISTING UST DISCOVERED: 410b FACILITY ID # (Agmcy Use Only).. :..a t i I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Bmircss As) 3 54 A)S ✓l.J / dam/ ✓ !7;tfev s 17 hi_ - BUSMESSSITE ADDRESS Im CITY J V 101 TANK@# 432 TANK MAN] IFACTURER435 TANKCONFIGuRATION THISTANR IS YY Vy/U�S C,2.J i'j A STAND-ALONE TANK 434 . ONE IN A COMPARTMENTED UNIT. C/ DATE UST SYSTEMINJALLED 455 /` /1 O Can ete me afwech as wdt TANK CAp,ra @I CAb ONS 436 NUMBER OF:OM�gR�NTS IN THE IT 437 TANK USE a. MOTOR VEMCLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (IndWa Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [MC4252ai.5(cB ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN 0'99. OTHER (Specify): 439& CONTENTS PETROLEUM: ❑ 1&. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 $-a. DIESEL ❑ S. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL 119.OTHER PETROLEUM 5 eci : 44W NON -PETROLEUM: ❑ 7. USED OIL10. ETHANOL I I. OTHER NONPETROLEUMS ed 440b TYPE OF TANK ❑ 1. SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL W. FIBERGLASS ❑ 6. INTERNAL BLADDER 4a ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER S eci 44& SECONDARY CONTAINMENT ❑ 1. STEEL .FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ T. JACKETED 445 ❑ 90. NONE - ❑ 95. UNKNOWN ❑99. OTHERS « 445& OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS 2.'T_2 OAT 3. FILL TUBE SHUT-OFF VALVE 4R. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVrJENTION EQUIPMENT �* PIPING CONSTRUCTION ❑ 1 SINGLE -WALLED id 2. DOUBLE -WALLED 1199. OTHER 40 SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION in CCR 163 & ) 459 PRIMARY CONTAINMENT 1. TEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specily): 4644 SECONDARY CONTAINMENT ❑ 1. STEEL d. FIBERGLASS ❑ a. FLEXIBLE ❑ 10. RIGID PLASTIC 4mb ❑ 90. NONE ❑ 93. UlNKNOWN 0 99. OTHER (Specify): 464' PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ LSINGLEWALL 1�: DOUBLE WALL ❑ 90. NONE 464d ' VENT PRIMARY CONTAINMENT ry _ I. STEEL 4. FIBERGLASS 10. RIGID PLASTIC W. NONE U 99. OTHER (Specii L J 464e VENT SECONDARY CONTAINMENT C7 .1. STEEL - . FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 461c1 Owl VR PRIMARY CONTAINMENT TTI. STEEL 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99.OTHER (Specify) L7 Own 4M9 VR SECONDARY CONTAINMENT 0 1. STEEL . FIBERGLASS 0 10. RIGID PLASTIC U 90. NONE C3 99. OTHER (Specify) 4M 1 464h VENT PIPING TRANSITION SUMP TYPE Ll t. SINGLE WALL OUBLE WALL 90'. NONE 9Mhl 4641. RISER PRIMARY CONTAINMENT .STEEL C1 4. FIBERGLASS U 10.RIGIDPLAsuI 90. NONE 0 99. OTHER (Specify) 464j RISER SECONDARY CONTAINMENT .STEEL d. FIBERGLASS l0. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464'1 464k FILL COMPONENTS INSTALLED ]. SPILL BUCKET L1 3. STRIKER PLATFIBPROTECTOR 4. CONTAINMENT SUMP 464k1 451&-c ,yOiTOM -''..•, . CONSTRUCTION FYPE ❑ 1. SINGLE WALL WDOUHLE WALL ❑ 3.DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL 1. STEEL �} d. FIBERGLASS "I0. RIGID PLASTIC ❑ 99.OTHER (SM19j,469b MAMMON "-- STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) CURRENT 1& 6. ISOLATION ❑�at' 4. 449. yynn�� *iIMPRESSED CERTIFICATION: I certify that this UST system Is compatible with the halardous substance stored and that the information provided herein Is true, accurate, and In full contrillmice with IffAl redfilmments. APPLICANT SIGNATURE DATE 470 APPLICANT NAME (print) ... APPLICANT T E 41$ A� L UPCF UST -B -1/2Rev. (12/2007)