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UNIFIED PROGRAM CONSOLIDATED FORM 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,111,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43a DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID A(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAM oing,Business As) 3 r9 N mac.. L , E or DBA-DF BUSINESS SITE ADDRESS 103 CITY MA J e IN P110 T IL TANK DESCRIPTION TANKED# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 EI 1.A ONE A COMPNETANK El2.ONE IN A COA7PARTMEMED UNIT. C ae one furls xNcudf. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS M THE UNIT 437 - 1 / 2 cru-z &i7 III.TANK USE AND CONTENTS TANK USE I..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lechNes USM ap ❑ 5.EMERGENCY GENERATOR FUEL IRSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: P4 Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIIJM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 1.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 44a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i : 44ab IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 212.DOUBLEWALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT '® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 El90.NONE ❑ 95.UNKNOWN 099.OTHER S eci 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 02.13ALLFLOAT ): 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 .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCR 52636(a)(3)) 458 PRIMARY CONTAINMENT g 1.STEEL ❑ 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464n SECONDARY CONTAINMENT ❑ 1.STEEL R 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4Md VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT V9 L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE In 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464n VR PRIMARY CONTAINMENT 1W L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mg 464 I VR SECONDARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Spmify) 4Nh 464h1 VENT PIPING TRANSITION SUMP TYPE ❑K, 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4M4 RISER PRIMARY CONTAINMENT /'] L STEEL 4.FIBERGLASS 10.RIGID PLASTIC RU90.NONE U 99.OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL E3 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 469k 46kl FILL COMPONENTS INSTALLED 5I.SPILLBUCKET 07-I 3.STRIKER PLAT&BOM PROTECTOR 0 4.CONTAINMENTSUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SMILE WALL [j2.DOUBLE WALL [13.NO DISPENSERS 1--] 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS R 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. 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. APPLIC IG ATU •!r f'-2-7-10 4W APPLIC N (print) /✓Q/I 471 APPLICANT TITLE 4R 7 UPCF UST-B-1/2 Rev.(12/2007)