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• 0 r UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK 124'S� 11I� OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo m pe UST) E 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) 430 1.NEW PERMPr El3.RENEWAL PERMIT [15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE C17.UST PERMANENT CLOSURE ON SITE C) 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4J0aDATE EXISTING UST DISCOVERED: 430b I. FACILITY WORMATION FACILITY ID#(Agency Use Only) P BUSINESS NAME_(S FACILITY NAME or BA-Doing Business As) 3 BUSINESS SITEADADDD`!WS t f� No CITY 104 YI.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 m / 1.A STAND-ALONE TANK -rAE]2.ONE A COMPARTMENTED.tin UNIT. Ca aeon p eforach emn mtin theunit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE ❑ la-MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ IC..AVIATIONFUELING 439 JS3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(induda UzW OiO ❑ S.EMERGENCY GENERATOR FUEL[HSC§=S1.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (S ify): 439. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ l..MIDGRADE UNLEADED ❑ Ib.PREMIUMUNLEADED 440 ❑ 3.DIESEL - ❑ 5.JET FUEL ❑ .AVIATION GAS - ❑ 8.PETROLEUM BLEND FUEL .OTHER PETROLEUM S eci6): ' v e 't 44th NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK I.SINGLE WALL [1 2.DOUBLE WALL [1 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 8848 SECONDARY CONTAINMENT ❑ 1.STEEL Ll 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION - ❑ 1.AUDIBLE&VISUAL ALARMS Lj 2.BALL FLOAT 0 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTIONLSINGLE-WALLED Cl2.DOUBLE-WALLED ❑99.OTHER 469 SYSTEM TYPE [:] I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 OCR¢2636(.)(3)I 452 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN Cl 99.OTHER(Spccify): 4648 SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46k PIPING)TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464E VI.VENT,VAPOR RECOVERY(VR)AND RISER FILL PIPE PIPING CONSTRUCTION::.: VENT PRIMARY CONTAINMENT 0 LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464c1 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46H 4640 VR PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.N0NE 0 99,OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464hi VENT PIPING TRANSITION SUMP TYPE ❑ LSME WALL [1 2.DOUBLE WALL 90.NONE El4641. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT LSTEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4Mk 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-c VII.UNDER'DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specifv) 469hc VIII. CORROSION PROTECTION y-�� STEEL COMPONENT PROTECTION E] 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT /t�IP.ISOLATION 442. IX: APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007)