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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK 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,Il,III,IV,and IX below) 410 ] 1.NEW PERMIT R 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Ll 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 9108 I DATE EXISTING UST DISCOVERED: 431h I. FACILITY INFORMATION FACILITY ID M(Agency Use Only) '_ u BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) r © 5 tot CITY 104 BUSINESS SI AD SS eh( oe Trc, L, W = II.TANKDESCRIPTION TANK IDM 432 TANK MANUFACTURER 013 TANK CONFIGURATION: THIS TANK IS 434 ,a„� H n A ['TASTAND-ALONE TANK {V-O W ❑2.ONE IN A COMPARTMENTED UNIT. Comlar one page for..ecapsoueent in the unit ATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS IN THE UNIT 437 (�. 1 10 112 0 U WIMMWIII. TANK USE AND CONTENTS TANK USEr1 a.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING Q Ic.AVIATION FUELING 039 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Onduder Wed Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125ni.5(c)) 04 6.OTHER GENERAKR,FUEL ❑ 95.[UNKNOWN ❑ 99.OTHER (Specify): 4398 CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ le.Iv)IDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 400. NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): Odra IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT [•}'1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINMG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 44M :CONDARY CONTAINMENT ❑ 1.STEEL W.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED w5 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTFIBR S 'fy): MS• OVERFILL PREVENTION ®'I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT ;; PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED [T2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE M-1-PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCR 12636(•)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 6r4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 460 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ify): Oso• SECONDARY CONTAINMENT ❑ 1.STEEL ®'4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46ac PIPING1 URBWF CONTAINMENT SUMP TYPE Q7.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464c VL VENT,VAPOR RECOVERY")AND RISER/FILL PIPE.PIPINGCONSTRUCTION VENT PRR IARY CONTAINMENT [a}ol.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N-90.NONE ❑ 99.0THER(Specify) 464f 464n VR PRIMARY CONTAINMENT 52'1.STEEL 0 4.FIBERGLASS ❑ I o.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 92090.NONE ❑ 99.OTHER(Specify) dbdh 461h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0.NONE dbdi. RISER PRIMARY CONTAINMENT W-L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC u 90.NONE El 99.OTHER(Specify) eb il RISER SECONDARY CONTAINMENT 0 1.STEEL Bd'd.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 13 99.OTHER(Specify) 4Wk a64h1 FILL COMPONENTS INSTALLED IH'I.SPILL BUCKET ❑ 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAB4WNT SUMP 451. VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Ba-1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAE. ❑ I.STEEL ❑ 4.FIBERGLASS 9 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696 ' VIII:-CORROSION PROTECTION` STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 2-6.ISOLATION 448 IX`APPLICANT SIGNATURE '.RTIFICATION: I certify that this UST system is compatible with the hazardous substance stared and that the information provided herein is true,accurate, and in full compliance with legal requirements. APP SI 7URE DATE 470. 1 as sola _ APP[ NAME tint} °71' APPLICANT TITLE 413 Jeh.n