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� Cr <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK ( I <br /> OPERATING PERMIT APPLICATION7 - TANK INFORMATION (One form er US <br /> TYPE OF ACTION (Check orte item o itv. For a UST closure or removah complete on(v this section and Se��ec�,�clJJJJJggPgPns 411'l i./Y,and IX below/ 430. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 1�5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE �❑ 8.UST REMOVAL <br /> DATE UST PERMANENCY CLOSED: 430. DATE EXISTING UST DISCOVERED: 43on <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAM (Same as Faci(iN_ N1. <br /> eor DBA-Doing Business sJ <br /> - / �- . <br /> !`N t. <br /> ROSINESS SITE ADDRESS -" i93. CITY O n /' <br /> l..i Pliy '-CJa 104. <br /> II. TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> o5bt Ly ASTAND-ALONE TANK Complete..e Iog'.reazh <br /> DATE UST SYSTEM INSTALLED °.ONE INA COMPARTMEMED UNIT ampvunent in Ne wic <br /> /G A35 TANK CAPACITY M GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437, <br /> 06 O <br /> III. TANK USE AND CONTENTS <br /> TANK USE - a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> 3.CHEMICAL GENERATOR <br /> STORAGE ❑ 4.HAZARDOUS WASTE Oralutla Used Oii) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§_'5181.5(.)] <br /> _❑ G.OTHER GENERATOR FUEL_ ❑ 95.UNKNOWN_ ❑ 99.OTHER(Specify): 439a <br /> CONTENT$ PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Ib.PREMIUM UNLEADED 440. <br /> ❑ 7.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> 8.PETROLEUM BLEND FUEL __❑ 9.OTHER PETROLEUM(Specify):_ ygog <br /> NON-PETROLEUM: 7.USED OIL 1:110.ETHANOL ---------- <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): <br /> 440E <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK I.SINGLE WALL _3.DOUBLE WALL 9t UNKNOWN J43 <br /> PRIMARY CONTAINMENT <br /> ❑ L STEEL 3.FIBERGLASS --_ <br /> ❑ 6.INTERNAL BLADDER q4y <br /> ❑ 7.STEEL+INTERNAL LINING _ 95.UNKNOWN ❑ 99.OTHER(Specify): 444. <br /> SECONDARY CONTAMMENf Q 1.STEEL �3,FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE__ 95.UNKNOWN ❑99.OTHERISpecify): 445. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE d VISUAL ALARMS ❑ ?,BALL FLOAT 3.FILL TUBE HUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVER LL PREVENTION UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> _PIPING CONSTRUCTION _0 1.SINGLE WALL 2.DOUBLE WALL_❑ 99.OTHER __ 4m <br /> SYSTEM TYPE PRESSURE �=.GRAVITY ❑ 7,CONVENTIONAL SUCTION_❑ 4.SAFESUCTION_3CCR§_636(L 458. <br /> PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE [2--" -- <br /> 90 NONE 1 ❑ 10.RIGID PLASTIC 461. <br /> 95.UNKNOWN _0 99.OTHER(Specify): y6gs <br /> SECONDARY CONTAINMENT ❑ 1.STEEL �'4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646. <br /> __._..-_ ___❑ 90.NONE____❑ 95.UNKNOWN C 99.OTHER(Specify): 464. <br /> PIPINGlI'URBINE CONTAINMENT SUMP TYPE L SINGLE WALL 2.DOUBLE WALL ❑ 90.-NONE ----464d-. <br /> VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 464e <br /> --.- ---_.._-__-_ _ ❑ 99.OTHER ISP..ify):_ 464e1. <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4. 4 -1 <br /> FIBERGLASS ❑ 10.RIGID PLASTIC I�.90 NONE <br /> -- -__---- _ ❑ 99.OTHER(Specify): <br /> VR PRIMARY CONTAINMENT -- J64Fl <br /> LSTEEL -'- <br /> -[1 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):i�lg <br /> VR SECONDARY CONTAINMENT - --- +6^'1. <br /> Q 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC $90.NONE ❑ 99.OTHER(Specify): �I` <br /> VENT PIPING TRANSITION SUMP TYPE , -- -- ------ 461h1. <br /> ❑ LSINOLE WALL ❑ _ DOUBLE WALL 990 NONE 4 i. <br /> RISER PRIMARY CONTAINMENT L STEEL - <br /> ❑ 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 4 <br /> RISER SECONDARY CONTAINMENT ❑ I:STEEL 4.FIBERG ASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 4641 <br /> FILL COMPONENTS INSTALLED ❑ 99 OTHER(Specify): 4Nkl <br /> 1.SPILL BUCKET -STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451--c. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL <br /> __._ ______..___. ___-.-_._____.___.__"______.____.._-__� 3.NOD ISPENSERS_ 0 90.NONE__..._.._..__469. <br /> CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S 4698 <br /> pacify) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION - 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: [ certify that this UST system is compatible with the hazardous substance stared and that the information providgd hemi. is [rue, <br /> accur e,and fiance with le al re irements. r - <br /> APPLICANTSIGNATU ` O, DATE / ry F 470. <br /> APPLICANT NAME(print) �4n. APPLICANT TITLE T1�2 4T. <br /> wJ <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org <br />