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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,11,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: 431, DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION FACILITY M#(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 sem. tl 06 0 01N BUSINESS SITE ADDRESS 153T CITY,TO 104 H.TANK DESCRIPTION TANK M# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 C D/+f TJX J N 117 1%17- 93. .A STAND-ALONE IN COMP TANK 2.ONE IN A COMPARTMENTED UNIT. SOLO TJd NS Complete one pase for each com a gmen in the unit DATE UST SYSTEM INSTALLED a35 TANK C CITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 L GJa c .TANk USE AND CONTENTS TANK USE :g la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ le.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC§25281 S(e)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: JQ is.REGULAR UNLEADED ❑ lo.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 440 ja 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM Sec' 4401 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL JR 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 2C 3,FIBERGLASS 0 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 4441 SECONDARY CONTAINMENT ❑ 1.STEEL 143.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S i4451 aMFILL PREVENTION IN 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHIM'-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 [199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CSR§2636(.x3)) 458 PRIMARY CONTAINMENT 01' 1.STEEL ❑ 4.FIBERGLASS [38.FLEXIBLE ❑ 10.RIGID PLASTIC 464 1190.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 PIPINGMJRBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL LJ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/.FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 13 I.STEEL ® 4.FIBERGLASS U 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 0 1.STEEL $3 4.FIBERGLASS ❑ 10.RIGID PLASTIC tj 90.NONE ❑ 99.OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC L3 90.NONE ❑ 99.OTHER(Specify) 4646 46491 VR SECONDARY CONTAINMENT 0 1.STEEL JD 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 19 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT 1,STEEL U 4.FIBERGLASS El 10.RIGID PLASTIC U 90.NONE ❑ 99-OTHER(Specify) 464) 464j] RISER SECONDARY CONTAINMENT Ll 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 4641 464kl FIILCOMPONENTS INSTALLED 1.SPILL BUCKET 3.STRW-ERPLATEMOTTOM PROTECTOR 3f 4.CONTAINMENT SUMP 4511< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691 CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-,c 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 r uire PLICANT SIGNA DATE 470. APPLICANT NAME(print) 471. APPLICANT TITLE C O p 4n. I lPrr IiRT-R-1(2 Rev.(7 2/2(()7)