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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 UST permanent closure or removal,complete only this section and Sections I,II,Ill,IV,and IX below) 430 r] 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL 4504 DATE EXISTING UST DISCOVERED: 4306 DATE UST PERMANENTLY CLOSED: I. FACILITY INFORMATION I FACILITY ID#(Agency Use Only) - - 3 BUSINESS NAIv1E(Same as FACILITY NAME or DHA-Doing Business As) Lkrtr BUS SS TE ADDRESS 105 CITY 1p° I_d e T r 0 r- IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 .T-AANK CONFIGURATION: THIS TANK IS a14 TG n I !N r.r 0 LI) LR cr.A STAND-ALONE TANK 1'� ❑2.ONE INA COMPARTMENTED UNIT. Com 1pe one for uch com emmrntin the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY CIITY I GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 2 �. III.TANK USE AND CONTENTS ` TANK USE I e.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING i39 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iodudo Uaea oil) ❑ 5.EMERGENCY GENERATOR FUEL RISC§25281 5(CI] 4344 ❑ 6.OTHER GENERATOR FUEL [195.UNKNOWN ❑ 99.OTHER (Specify): CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED ;4o (a'S.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 44ab El1 I.OTHER NON-PETROLEUM(S eci ): IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT Lt 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER IS Masa SECONDARY CONTAINMENT ❑ I.STEEL LRI.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED Mas ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): us. JVERFILL PREVENTION 2'1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENT$FOR EXEMPTION FROM OVERFILL,PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 82.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE OR-1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION h CCR 62636(x93)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL GY4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464° SECONDARY CONTAINMENT ❑ 1.STEEL Hkil.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461c PIPING,TURBINE CONTAINMENT SUMP TYPE la-T.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LWI STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [5)190.NONE ❑ 99.OTHER(Specify) 4Mf awn VR PRIMARY CONTAINMENT DUA.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE 99.OTHER(Specify) 464a 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC [9}90.NONE 0 99.OTHER(Specify) a64h 4Mh1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL M'90.NONE a i A4.FIBERGLASS . RISER PRIMARY CONTAINMENT [�.1.STEEL ❑ ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 aha t RISER SECONDARY CONTAINMENT 0 1.STEEL Er4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a64k 464kl FILL COMPONENTS INSTALLED 9�-I.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4s1a-e VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE EM 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46ye CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS al 0.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT Q3,,ii.ISOLATION 448. LY. APPLICANT SIGNATURE CERTIFICATION: l certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. 470. APPLICANT SIGNATURE DATE IIz2�a010 APPLI NAME(print) Yan. APPLICANT TITLE 4�2. r. l