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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. Form UST permanent closure or removal,complete only this section and Sections 1,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430i DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or BA-Doing flusiness As) 3 MKTJ+e-r `v'o'lt re BUSINESS SIT DDR SS ;N sr I' CITY r, ivN l0/ I.TANK DESCRIPTION 1- TANK 11)# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 IlIaNM.A STAND- ANE TANK IM'w5iv^f�`yy� [12.ONE MACOMPARTMENTED UNIT. tit OM Cfm nl'A is lhlwtil. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 14- W21i 4 \ l tr u p X71,4. III.TANK USE AND CONTENTS TANK USEIa.MOTOR VEHICLE FUELING Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 V [I3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iacl Us 011) ❑ 5.EMERGENCY GENERATOR FUEL[HSC$25281d(eB ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Mb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I I.OTHER NON-PETROLEUMS 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL IR 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ].STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4Na SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S i ): 445a OVERFILL PREVENTION ❑ 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 ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVrrY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In cm§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE El10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL [A 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 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL IR 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0-99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEELI37 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 469f 4Mfl VR PRIMARY CONTAINMENT ( 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4648 461 1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 41Ah 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464j d64'1 RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE Cl 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR rj 4.CONTAINMENT SUMP 0451a.�VII.UNDER DISPENSER CONTAINMENT WDC)CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONECONSTRUCTION MATERIAL ❑ 1STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify)VII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURECERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is tru and in full compliance with legal requirements. APPLIC S NA UREDATE U a '°0 - � _ APPLI NAME(prinQ .f r vN4 411 APPLICANT TITLE/` N&,A_ a 4r.. UPCF UST-B-1/2 Rev.(12/2007)