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V 00 • UNIFIED PROGRAM CONSOLIDATED FORM 12 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) as TYPE OF ACTION (Check one item only. Foran 1 'permanent closure or removal,complete only this section and Sections I,IL III,IV,and IX below) 4N) ❑ 1.NEW PERMIT Ct}3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J011 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUS 22�r "' �[LITY NAME or DBA-Doing Business As) 3 BUS SS SITE AQDRE • �.0 / Mol CITY ` �A. IIs 19 II.TANK DESCRIPTIONLj' TANK /SID##,��.�y 432 TANK/MANUFACTURER 033 TANK CONFIGURATION: THIS TANK IS 4M 9 .ONE I NA ALONECOMMA TANK G [�L.ONE IN A COMPARTMENTED UNIT. eeoro forach main Neu'c DATE UST SYSTEM INSTALLED 435 TAN APACITY IN G9LLQNS• 436 NUMBER QW.44WARTMENCLi l' E UNIT 437 III.TANK CUSE`AND CONTENTS o L. TANK USE Wolfs.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ Ic.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(I Judet Uwaoi0 ❑ 5.EMERGENCY GENERATOR FUEL(HSC 425281.5(c)] ❑ 6.OTHERGENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 2.1.DIESEL ❑ 5.SEI'FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM 5 eci : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ IL.OTHER NON-PETROLEUM 5 i : Wb IV..TANK CONSTRUCTION TYPEOF TANK ❑ 1 SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN /4J PRIMARY CONTAINMENT Llor 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER dd4 ❑ 7.STEEL+INTERNAL MG CI 95.UNKNOWN ❑ 99.OTHER S SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOC'99.OTHER IS ): 445s OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS WN .BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRO DUCTlWASTEPIPING CONSTRUCTION PIPING CONSTRUCTION ❑ISINGLE-WALLED 2.DOUBLE-WALLED 099.OTHER 469 sat SYSTEM TYPE LPRESSURE ❑ 2. RAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 3CCR92636(a H] 456 PRIMARY CONTAINMENT ❑ [.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 9 UNKNOWN ❑ 99.OTHER(Specify): a64a SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN CI99.OTIE3R(Smcify): dbdc PIPING?URB INE CONTAINMENT SUMP TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464 VI.VENT,VAPOR RECOVER (VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC El 90.NONE CI 99.OTHER(Specify) 464 4641 VENT SECONDARY CONTAINMENT L STEEL C3 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464f 4Mn VR PRIMARY CONTAINMENT ❑ 1.STEEL W4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE C3 99.OTHER(Specify) 4644 464 I VR SECONDARY CONTAINMENT 1.STEEL -in 4.FIBERGLASS 0 10.RIGID PLASTIC 9 .NONE 99.OTHER(Specify) 464 6MI VENT PIPING TRANSITION SUMP TYPE .SINGLE WALL 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT Hd 1.STEEL FIBERGLASS ❑ 10.RIGIB PLASTIC LJ 90.NONE C3 99.OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT 1.STEEL hd 4.FIBERGLASS IC 10.RIGID PLAST90.NONE 99.OTHER(Specify) 464, 461k1 FILL COMPONENTS INSTALLED LVI.SPrLLBUCKET 3.STRIKER PLATUBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE L INCLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 49bs VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.EMPRESS: CURRENT .ISOLATION a98. APPLICANT SIGNATURE CERTIFICATION: 1 certify s U s comps 1 with the hazardous substance stored avd[ha[the ivformudea provided hereiv is frog accuratq and in fu a Ire Maui vis. APPLICANT SIGNATURE DATE / 2 G Oro_ APPLICANT NAME(print) 471' APPLICANT TRLE'T , - (J 7 4P, UPCF UST-Q-t2 CJ�/`s Rev.(12/2007)