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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK It INFORMATION(One Rolm pa UST) TYPE OF ACTION (Check one item only. Foran UST perm®ent clown mrelmval,compute only mis section and Sections L 41II,ry,and IX below) 439 ❑ I.NEW PERMIT [13.RENEWAL PERMIT S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 41), DATE E7USTIN0 UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY ID N(Agmry U4e Only) - 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) _ 3 BUSINESS SITE ADM In3 ClT'Y la rl/ zia,5'7 LAyE TQC�� IL TANK DFSCRUMON TANK IDH /�/ 432 TANK MANUFACTURER 433 TANK CONFIGURATION:TTR9 TANK M 434 D ✓K �O 1 92.ONE INACOWARATMENf®UNIT. -rA �� ameow DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III TAW UR AND CONTENTS TANK USE IKMOTORVE(RCLEFUELiNG ❑ mmARiNAFOQ.ING 0 ICAVIATIONFUELING 439 3.CHBIICALPRODULTSTORAGE 04.HAZARDOUS WASTE(Ivdd.Us Oa) 13 5.EMERGENCY GENERATOR FUEL It=425,sLA()] ❑ 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER(Spaafy): 43% CONTENTS PETROLEUM: 0 la REGULAR uNLFADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED ma J9 3.DIESEL 0 5.IEf FUEL 0 6.AVIATION GAS 0 S.PETROLEUM BLEND FUEL 0 9.OTHERPETROLEUM 40A NON-PETROLEUM:0 7.USED OIL 0 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 4406 IV.TANKCONSTRUCTION.. _ - TYPE OFTANK ❑ I.SINGLE WALL ®2DOUBLE WALL 095.UNKNOWN N3 PRIMARY CONTAINMENT' 111.STEEL 3.FIBERGLASS ❑6.INTERNAL BLADDER a4a 0 7.STEEL+INI'S NALLiNING ❑95.UNKNOWN ❑99.OTHER (specify): 444. SECONDARY COMAI4MENf [] I.STEE, T$3.FIBERGL ❑ 6.EXTERIORMEMBRANELANER ❑ 7.JACKETEO 445 ❑ �.NONE []95.UNKWN NO99.OTHER(S ): 4450 OVERFILL PREVENTION 1.AUDIBLE 1k VTSUALALARM9 2.BALL FLOAT 3.FILL TUBE SNTF-0PP VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQGIPMFM .Vs PRODUCT/WASTEPIPINGCONSTRUCTION PIPING CONSTRUCTION ❑1.SIN JLE WALLED -DOUBLE-WALLS) ❑99.GTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑3.CONVENDONALSUCIION 0 4.SAFE SUCTIONl73CCR93636( B ase PRIMARY CONTAINMENT 1.STEEL K 4.FIBERGLASS 0 R FLEXIBLE ❑ IQ RIOm PLASTIC 461 0 90.NONE 0 95.UNKNOWN 0 99.OTHIX(Spocify): 464a SECONDARY CONTAJNWNT 01.STEEL 4.FIBERGLASS El &FLEXIBLE 010.RIGID PLASTIC 464b 0 90.NONE 95.UNKNOWN 0 v9.07'xRR(spe i : 464c PIPINGTTURBINE CONTAMMEMSUMP TYPE W I.SINGLEWALL 02.DOUBLE WAIL 090.NONE a6a4 VL VENT,VAPOR RECOVERY(VR);AND RISER/FILL PIPE PIPING CONSTRUCTION DM VENTPRARYCONTAINMENT I.STEEL IEL 4.F'IBERGLA'SU to.RIGID PLASTIC 90.NONE 99.0T'HER(SpmTy) 464e 46k1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 30.RIGS PLASTtC 90.NONE 99.OTHP3i('Entity) 464f VR PRIMARY CONTAINMENT 0 T.STEEL IQ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(S,.*) Wfi 4648 VR SECONDARY CONTAR4Mfr34T [3I.STEEL [14.FIBERGLASS [31 464 1 IO.RIGIDPUN C 90.NONE 99.OTHER(Speetfy) 464h 4Nh1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0LL 90.NONE 4 L RISER PRIMARY CONTAINMENT1.STEEL 4.FIBERGLASS ❑ IILRIGM PLASTIC u W.NONE U 99.OTHER(Spa;i*) 4641 464'1 RLSERSECONDARYOMAINMENT 0 1.STEEL 09 4.FIBERGLASS 10-RREDPLAyDC 90.NONE 0 99.OTHER(Specify) 464k 4Mkl FIA,COMPONENTS INSTALLED I.SPILBUCKer JUSTMERPLATEGOTTOMPROTECTOR 04.COMAINMM>ENTSUMP 451.4 VEL UNDERDISPENSER`CONTAINMENT.(UM ONSTRUCTION TYPE1.SINGLE WALL U 7 DOUBLE WALL ❑3.NO DISPENSERS 0 90.NONE 469, CONSTRUCTION MATERIAL 1.STEED 4.FIBERGLASS 0 l0.RIGID PLASTIC 0 99 OTHER(S ) 469b4 .. . .VIII-CORROSION-PROTECTION STEELCOMPONENTPROTECTION 0 25ACRIFICIALANODE(s) 0 4.0"RBSSED CURRENT IlU 6.15011,TION 44K IR. APPLICANT SIGNATURE CERTIFICATION: I eerdfy that mh UST system Is compatible with the haardom substance stored and that the iufotmatiou provided he.U true,a..t., and In full aro nts. APPLICANT SIGNATU - DATE 4m. Jl�/ O APPLICA f NAME 4n. APPLICANTfITLE 472. UPCF UST-B.U2 Rev.(1212007)