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12-' V <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK I�-C <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One rapt,Par UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,1V,and 1X below) 430. <br /> ❑ 1.NEW PERMIT &K.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) t' <br /> BUSINESS NAME•ISas Foci/' Name or OBA-Doirtg Business As) 3_ <br /> r5io <br /> BUSINESS SITS ADDS 103. CITY�ke �Z Q 104. <br /> II. TANK DESCRIPTION <br /> TANK ID N4)2. T K MAN 1�FA-CTURER 433. TAr_JK CONFIGURATION:THIS TANK IS +36, <br /> (fi S i/LuS ee i�9r✓K ��CI.A STAND-ALONE TANK <br /> ❑ Conryleuone page forsacM1 <br /> O� y 2.ONEINA COMPARTMENTED UNIT wmpmlmmrletheoelt <br /> DATE UST SYSTEM INSTALLED 435_ TANKf APACITY IN GALLO�s 436. NUMBER OF COMPARTMENTS IN THE UNIT 437, <br /> 2 oao � <br /> III. TANK USE AND CONTENTS <br /> TANK USE lf. OTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(mclW Us OR) [1 5.EMERGENCY GENERATOR FUEL IBSC g25281.5(c)] <br /> ❑ 6.OTHER GENERAT L ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: Nrl..REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Spxify): 440` <br /> NON-PETROLEUM: 7.USED OIL b 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM($ ify): 440h <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL _.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT DR1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> _ ❑ 7.STEEL INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a <br /> SECONDARY CONTAINMENT ❑ 1,STEEL QTFIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED <br /> ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(Specify): 45a <br /> OVERFILL PREVENTION ❑ I.TANKAUDIBLE&ETS REQUIREMENTS <br /> 2.EMPTIO FROM <br /> .FILL TUBE SHUT-OFF VALVE -4R. <br /> ❑ 4.TANK MEETS RE UIREMENT$FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION . _� l NGLE WALL jr2.DOUBLE WALL ❑ 99.OTHER 4W <br /> �j SYSTEM TYPE vt PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑_4.SAFE SUCTION['J CCR§±636(a)]B 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN [399.OTHER(Spmify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464h <br /> ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 464° <br /> PIPING/I'URBINE CONTAINMENT SUMP TYPE Irl.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 460d <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464ej_ <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 1] 99.OTHER(Specify): 4644111, <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 1.FIBERGLASS [3 10.RIGID PLASTIC ❑ 90.NONE C] 99.OTHER(Specify): q4 b <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL [3 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 464h <br /> 464h1. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL yy+o.NONE i., <br /> RISER PRIMARY CONTAINMENT 1p1.STEEL ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE [399,OTHER(Specify): 4M i_ <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLA ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g4ML <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET .STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE .SINGLE WALL ❑ 2OLL ❑ 3.NO DISPENSERS ❑ %.NONE 469a <br /> .DOUBLE WA --_- _ - 4691, <br /> CONSTRUCTION MATERIAL 1.STEEL Cl 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46p <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SAC ROa('IAL ANODES) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX ICANT SIGNATURE <br /> CERTIFICATION: i ..rd I th U T ys is comps ib with the hazardous substance stored and ththe informatlon provided herein is true, <br /> •eeum 4fin ful p with len uiremenb. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 471' APPLICANT TITLE 412- <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org <br />