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�I UNIFIED PROGRAM CONSOLIDATED FORM f� /D UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (Dne form per LIST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,ll,I/I,1V,and IX below) 430. �.r ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE L3 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4.30. 1 DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BU SSNAME F Npam(eI of,r 41BA-Do' Burimss As) 3. BUS $s SITE]DDRES ti 3 w tai. CITY lo,' II. TANK DESCRIPTION TANK ID# 433. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 0 I.A STAND-ALONE TANK Cowide one page for eaeb itsTA 0 2.ONE IN A COMPARTMENTED UNIT compnrneent,s tlw--I DATE UST SYSTEM INSTALLED 03d TAN�ACI YI`GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANKUSE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 It.AVIATION FUELING 439. 3.CHEMICAL PRODUCT STORAGE 0 dDe4 4.HAZARDOUS WASTE(loodee d W) [1 S.EMERGENCY GENERATOR FUEL 9M yuzal.5(c)] 0 6 OTHER GENERATOR FUEL._._ 0 95.UNKNOWN _ _......__ 0..99.OTHER(SpedCy): 439. CONTENTS PETROLEUM Ia REGULAR UNI,F.ADED 01c.MEOGRADE UNLEADED 0 lb.PREMIUM UNLEADED 440 Ej 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS _ ❑ 8.PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM(Spa ify)_ NON-PETROLEUM:[] 7.USED OIL 0 10 ETHANOL 0 11.OTHER NON-PETROLEUMS 44ob V. TANK CONSTRUCTION TYPE OF TANK 0 L SINGLE WALL 2.DOUBLE WALL- 0 95 UNKNOWN w. PRIMARY CONTAINMENT 0 1.STEEL 3.FIBERGLASS 0 6.INTERNAL BLADDER 400' 07.STEEL+INTERNAL LINING 095.UNKNOWN. ❑,99_OTHER(Spedfy): *ua SECONDARY CONTAINMENT 0 1.STEEL 0 3.FIBERGLASS 0 6 EXTERIOR MEMBRANE LINER 0 7.JACKETED a5. 0 90,NONE 0 95.UNKNOWN 099 OTHER(SpedJ§): M5. OVERFILL PREVENTION 0 LAUDIBLE&.VISUALALARMS ❑ 2.BALLFLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2 DOUBLE WALL._ 0 99 OTHER 460' SYSTEM TYPE _ 0 1.PRESSURE 2 GRAVITY_ 0-3 CONVENTIONAL SUCTION 0.4.SAFE SUMONJ23 CCR§XIAW 4% PRIMARY CONTAINMENT 0 L STEEL .��1F4.FIBERGLASS 0 8 FLEXIBLE 0 10.RIGID PLASTIC 464 0 90.NONE (,J 95.UNKNOWN 0 99.O HER(Spmty) 464 SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS Q 8.FLEXIBLE 0 10.RIGID PLASTIC 4646. 0 90.NONE ❑ 95.UNKNOWN_. 99 OTHER(Sped�_ 46� PIPINGlFURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE 0 W.OTHER(Specify} ,dg6�3eI' VENT SECONDARY CONTAINMENT ❑ 1.S1EEL 4.FIBERGLASS ❑ lo.RIGID PLASTIC [I90.NONE [I W.OTHER(Specify) rt VR PRIMARY CONTAINMENT ❑ 1.S'TFFET.. 4.FIBERGLASS [1 10 RIGIDPLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 6 VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPecify) 4646' 4N61. ............_-_ _ VENT PIPING TRANSITION SUMP TYPE - 1.SINGLE WALL 2 DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT 0 1 STEEL 4.FIBERGLASS 10 RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify). j RISER SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify): 4Hkl FILL COMPONENTS INSTALLED91 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451'0 UNDER DISPENSER ONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1 SINGLE L 2 DOUBLE.WALL 0.3 NO DISPENSERS 0 90.NONE 469^ CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 0 99.OTHER(Specify) �q VIII. ORROSION PROTECTION STEEL COMPONENT P O ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44g. IX. APPLICANT SIGNATURE CERTIFICATION: I cern that this UST system is compatible with the hasardous substsoce stored and that the information provided herein is hoe, `. accurate and in full co cc i h legal requirements. APPLICANT SIGNATURE DATE APPLICANT NAME(point) a _vi�/021'_ APPLICANT E u-c 'ter UPCF UST-B Rev.(12n007)-1/2 www.uddoeaorg