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UNIFIED PROGRAM CONSOLIDATED FORM ( O UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 136 �I.NEW PERMIT El 3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430aI DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY[D N(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) n 3 t T 2 BUSINESS SITE ADDRESS _,_ 103 CITY 163 C�a G II.TANK DESCRIPTION TANK D)O 432 TANK MANUFACTURER 433 TAMC CONFIGURATION: THIS TANK IS 434 �// �a / I.A STAND-ALONE TANK [12.ONE M A COMPARTMENTED UNIT. Co ae one fm aeh com as is Ne umc DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 -2,0 111.TANK USE'AND CONTENTS 1�dIC::S`c a ie.1.IOTOR bEHICLE FUELING ❑ Ib.MARINA FUELING ❑ I..AVIATION FUELING 439 >.3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ind.da Use D0 ❑ 5.EMERGENCY GENERATOR FUEL CHSC 125231.5(c)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MHXHLADEUNLEADED ❑ Ib.PREMIUM UNLEADED 446 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS - --- - ❑ S.PETROLEUM BLEND FUEL9.OTHER PETROLEUM (S eci ): 440a NON-PETROLEUM:❑ 7.USED OIL 2P 70.ETHANOL ❑ II.OTHER NON-PETROLEUM(8 i ): 4406 W. TANK CONSTRUCTION TYPE OF TAMC jjjol.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL U 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING [395.UNKNOWN E399.OTHER (S ec" ): 444e SECONDARY CONTAINMENT ❑ L STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 445. OVERFILL PREVENTION 0 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION LSINGLE-WALLED El 2.DOUBLE-WALLED El 99.OTHER 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 1'_3 CCR 42636(.)(3)1 453 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS [1-8.FLEXIBLE ❑ l0.RIGID PLASTIC 464F ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER IFELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL Lj 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464c1 VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464B VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) 4648 46421 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 01.SINGLE WALL F3 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ t0.RIGID PLASTIC ❑ 90.NONE LJ 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 4641, 4641 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET Cl 3.STRIKER PLATE(BOTTOM PROTECTOR ❑ 4.CONTALNNIENT SUMP 4510-. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS Cl 90.NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT '6.ISOLATION 443. 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 SIGNATUREDATE 470. APPLICANT NAME(print) 4n. 1 APPLICANT TITLE 472, VPCF UST-B-1/2 Rev,(12/2007)