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&A41,3 n UNIFIED PROGRAM CONSOLIDATED FORM z UNDERGROUNDSTORAGETANK y/ OPERATING PERMIT APPLICATION-TANK INFORMATION(one form MUST) TYPE OF ACTION (Check one item only. Foran UST pemlanent closure or removal,complete only this section and Sectiore I,Q II,IV,and IX below) ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION �� (�, 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL L (i. DATE UST PERMANENTLY CLOSED: 030' DATE EXISTING ST DISCOVERED: <� L FACILITY INFORMATION FACILITY ID 4(Agency Use Only) BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business i .j iiC-�= \ cam` 1a BUSINESS SITE DRESS )03 CITY U.TANK DESCRIPTION TANK IDd 432 TANK MANUFACTURER 433 TANKCONFIGURATION: THIS TANK IS 430 %L A STAND-ALONE TANK 1 [12.ONE IN A COMPARTMENTED UNI. \ 1 \JJC. �%':J Mme famL hm tlw ioit D TE UST SYSTEM INSTALL 435 TANK CAPACITY IN GALLONS 436 NUMBE O COMPARTMENTS IN THE UNIT 437 �� ,UwN t On I Citi in.TANK USE AND CONTENTS TANK USE Ic MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICALPRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE(MUsed Oa) ❑ 5.EMERGENCY GENERATOR FUEL W U5241.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 43% CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MWGRADE UNLEADED ❑ ib.PREMUM UNLEADED 44D ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL SL9.OTHER PETROLEUM S Cel <>! \�n'•'ls- aaa NON-PETROLEUM:❑ 7.USED OIL ❑ E0.ETHANOL 04W ❑ 11.OTHER NON-PETROLEUMS ' IV. TANK CONSTRUCTION TYPE OF TANK L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT J4 1.STEEL ❑ I FIBERGLASS ❑ 6.INTERNAL BLADDER 404 ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN 99.OTHER S 4M. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 005° OVERFILL PREVENTION - LAUDBLEa.VISUALALARMS 2.BAILFLAAT d 3.FILL TUBE SHUT-0FFVALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIBNEEN'1' 4 V JQ .-Z,J V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION L SINGLE-WALLED 02DOUBLE-WALLED ❑99.OTHER 4O SYSTEM TYPE U 1.PRESSURE ❑ 2.GRAVITY .CONVENTIONAL SUCTION ❑ 4.SAFESUCI70N123CCR§2636(4)(3)) 45s PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN 1199.OTHER( ): 464e SECONDARY CONTAINMENT ❑ 1.STEEL ❑ k FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 460b 90.NONE ❑ 95.UNKNOWN El99.OTHER(S 'fft 064e PIPING?URBINE CONTAINMENT SUMP TYPE ❑ 1.SINULe WALL ❑2.DOUBLE WALL 90.NONE °fi°d VL VENT,VAPOR RECOVERY(VR)AND RISER/FEL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.MUM(Specify) 060e 6 e1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 13 10.RIGID PLASTIC 90.NONE 99.O'1'fIBR(Specify) TlI 460fl VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC P1 90.NONE 99.OTHER(Specify) 060g 46R[ VR SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 46M1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.1)OLBLE WALL 90.NONE 4601 RISER PRIMARY CONTAINMENT L STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC W.NONE w.OTHER(Specify) 4641 464l RISER SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464Y 0I ELL COMPONENTS INSTALLED 1.SPI.I.BUCKET 3.STRIKER PLA'IF/BOTTOM PROTECTOR 04CONTADOAEWSUTNWW 451.1 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE m9. CONSTRUCTION MATERIAL 0 L STEEL [3 4.FIBERGLASS ❑ 10.RIGID PLASTIC U 99.UTIBR(SPEW 469Dc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION (J Nknlf.�i aa. UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST systems table With the hourdom substanee stored fad that the information provided herein is true,s unte, and in full commislince with leW reqmhy mts. 430. APPL SIGNATURE DATE 4n. APPLICANT TITLE APP472 CANT�AME(prhd) �`� L? � UPCF UST-B-112 Rev.(12/2007)