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-4z _ v UNIFIED PROG CONSOLIDATED FORM UNDERGROUND STORAGE TANK l OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) Ute- -'PE OF ACTION (Check one item only. FN,rm UST permanent closure or removal, complete only this section and Sections I, IL III, IV, and IX be] o ) +30 CI, 1. NEW PERMIT 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATIONly� b. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE E. UST REMOVAL DATE UST PERMANENTLY CLOSED: 12-0.1 /3 430, DATE EXISTING UST DISCOVERED: 430b FACILITY ID M (Agency Use only) BUSINESS NAME (Same as FACI.FfY NAME or DBA -Doing Business As) 3 _ ✓l.J / b/ �li+C n us�7 BUSINESS SITE ADDRESS J� t' 103 CITY S •>/�G TON IN :TANK TANKIDN F 432 , NK MANI IFACTURER 1 433 TANK CONFIGURATION. THIS TANK IS /( j I C G I ( 04/(.It/S Cflx AJ "I � �1 ASTAND-ALONE TANK 434 �e11 YVI 'FWv'2 ONE IN A COMPARTMENTED UNIT. D ` Merdi. Q. NeL DATE UST SYSTEM -INSTAL D 435 TANK CA�CfSX� CA;,LONS 436 NUMBER OF S Al THE IT E 437 LC TANK USE i MOTOR VEHICLE FUELING 0 Ib. MARINA FUELING 0 le AVIATION FUELING 439 03. CHEMICAL PRODUCT STORAGE U4.HAZARDOUS WASTE (IncluduDied oil) 05. EMERGENCY GENERATOR FUEL plsc 4252e1,5(9)) [16. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑'99. TITHER (Specify): 4392 CONTENTS PETROLEUM: 0 I2. REGULAR UNLEADED ❑ 11. MIDGRADE UNLEADED 0 Ib. PREMIUM UNLEADED 440 $a. DIESEL ❑ 5. JET FUEL 0 6. AVIATION GAS 0 8. PETROLEUM BLEND FUEL 0 9. OTHER PETROLEUM (Specify): 4402 NON -PETROLEUM: 0 7. USED OIL U 10. ETHANOL IL OTHER NON -PETROLEUM 5 eci 440b TYPE OFTANK I. SINGLE WALL 2. DOUBLE WALL ❑95. UNKNOWN 4O PRIMARY CONTAINMENT U L STEEL W-3. FIBERGLASS U 6. INTERNAL BLADDER 0 7. STEEL+ INTERNAL LINING 0 95. UNKNOWN 0 99.OTHER (Specify): 444 4442 SECONDARY CONTAINMENT 0 I. STEEL AW. FIBERGLASS 0 6. EXTERIOR MEMBRANE LINER 0 7• JACKETED 445 0 90. NONE 0 95. UNKNOWN 1199.OTHER S ec' 4452 OVERFILL PREVENTION . AUDIBLE & VISUAL ALARMS BA 2. LLFLOAT J. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT PIPING CONSTRUC170N I. SINGLE -WALLED 2. DOUBLE -WALLED 099. OTHER q,e SYSTEM TYPE ❑ I. PRESSURE U 2. GRAVITY 0 3. CONVENTIONAL SUCTION 0:4 SAPS SUCTION x3 CCR 26)6(2X)) 458 PRIMARY CONTAINMENT I. STEEL 4. FIBERGLASS ❑ e. FLEXIBLE U 10. RIGID PLASTIC 464 ❑ 90. NONE 0 95. UNKNOWN ❑ 99.OTHER(Specity): 4642 SECONDARY CONTAINMENT I. STEEL 4. FIBERGLASS 0 8. FLEXIBLE 10. RIGID PLASTIC 469b 0 90. NONE 0 95. UNKNOWN 0 99.OTHER(Specify): 464. PIPINGTIl1RBINE CONTAINMENT SUMP TYPE U 1. SINGLE WALL �2 DOUBLEWALL 90. NONE 4Md VENT PRIMARY CONTAINMENT Q I. QEFl 4. FIBERGLASS U to. RIGID PLASTIC LJ 90. NONE El 99. OTHER (Specify) 464, VENT SECONDARY CONTAINMENT L1. STEE1. ' . FIBERGLASS I0. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 4NM 464f VR PRIMARY CONTAINMENT I. STEEL .FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 46411 464, VR SECONDARY CONTAINMENT 0 ].STEEL-- :FIBERGLASS I0. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 469 1 4641, VENT PIPING TRANSITION SUMP TYPE LSINGLE WAIL DGBLE WALL 90. NONE 464h1 4641. RISER PRIMARY CONTAINMENT .STEEL /. FIBERGLASS 10. RIGID PLASTIC 90. NONE 0 99. OTHER (Specify) 464j RISER SECONDARY CONTAINMENT . STEEL D 4. FIBERGLASS Ej 10. RIGID PLASTIC 90. NONE 0 99 .OTHER (Specify) 464jI_ 464k 464k1 FILL COMPONENTS INSTALLED 7. SPILL BUCKET Cj J. STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP ash -c CONSTRUCTION TYPE I. SINGLE WALL a7_DOUBLE WALL U3. NO DISPENSERS 090. NONE 4692 CONSTRUCTION MATERIAL 1. STEEL Ej I. FB3ERGLA55 �'i0. RIGID PLASTIC U 99. OTHER ftiw469b< STEEL COMPONENT PROTEC110N ❑ 2. SACRIPICIAL ANODES) ❑ 4. IMPRESS5StTED CURRENT 6."ISOLATION 448. CERTIFICATION: 1,W, thaf this UST system b compatible wIW the hazardous mbstanee riored and that the Information provided herein Is true, accurate, and to full core lance with 1 al re ulre nb. APPLICANT SIGNATURE DATE 470. L -�f APPLICANT NAME (prin /71' APPLICANT T E 47z. A� L UPCF UST -131 -112Rev. (1212007)