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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,11,111,IV,and IX below) 430 19 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4..a I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY 0#(Agency Use Only) I BUSINESS NAME(Satre as FACILITY NAME or DBA-Doing Business As) 3 sa rat 3-0A 9 01 N BUSINESS SITE ADDRESS 103 CITYS T C 104 II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 C c>NT la J N In n!T 12•A STAND-ALONE TANK r ❑2.ONE IN A COMPARTMENTED UNIT. w4"^ o(--V I 1 d S Complete onepage for each compWanent in the amt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Jli4ate9r, zmecz L ant III.TANrK USE AND CONTENTS TANK USE :ff la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL-(HSC g25281.5(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify} 439a CONTENTS PETROLEUM: JM la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 JE 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4402 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL Z 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 2C 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT 0 1.STEEL 3.FIBERGLASS 6,EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ��. ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Si445a OVERFILL PREVENTION 1.AUDIBLE dt 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 ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCA 26364)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPB4GfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL D9 4.FIBERGLASS 10,RIGID PLASTIC ❑ 90.NONE Ll 99.OTHER(Specify) 464c 46421 VENT SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE L3 99.OTHER(Specify) 464f 464(1 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPINGTRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464'. RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4641 464i i RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS t3 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4601 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE(BOT'rOM PROTECTOR 4.CONTAINMENT SUMP 451st VII.UNDER DISPENSER CONTAINWNT(UDC) CONSTRUCTION TYPE El 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [190.NONE 4692 CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b- VM. 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 fill Compliance with legal regulre 470. APPLICANT SIGNA DATE -i - ) p ) / ' 471. APPLICANT TITLE472. APPLICANT NAME(Print) �� P,�7--��7�C p c a IV 77R A c TDA,