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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,I,III,IV,and IX below) 430 <br /> -59 1.NEW PERMIT Q 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 031aI DATE EXISTING UST DISCOVERED: 430b <br /> L FACILITY INFORMATION <br /> FACILITY ID flAgency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> SA til OA 9 U L r,4 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> S'T <br /> II.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK LS 434 <br /> C(>r4 "T"XilAfJ77.En�T Rl.A STAND-ALONE TANK <br /> 1) S a�.V 7-10 h!S <br /> [12.ONE IN A COMPARTMENTED UNIT. <br /> Com ete one me for e*eh compartmew m aie unit <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> L L.Aa gki <br /> III.TANk USE AND CONTENTS <br /> TANK USE :9 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Iacluda Uxd pip ❑ 5.EMERGENCY GENERATOR FUEL(HSC§ mi s(q <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439* <br /> CONTENTS PETROLEUM: '0 la.REGULARUNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ lb.PREMIUM UNLEADED 440 <br /> 10 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM Sec 440* <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify); 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL .0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ i.STEEL 3.FIBERGLASS 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 4441 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 6.EXTERIOR MEMBRANE LATER ❑ 7.JACKETED 415 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445* <br /> /ERFILL PREVENTION 19 1.AUDIBLE&VISUAL ALARMS Ll 2.BALL FLOAT JS 3.FILL TUBE SHUT-OFF VALVE 152. <br /> ❑ 4.TANK MEETS REQULREMENTs FOR E ampTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED [12.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION R3 OCR 42636(1X3) 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE <br /> [390.NONE ❑ 95.UNKNOWN EJ ]0.RIGID PLASTIC 164 <br /> ❑ 99.OTHER(Specify): 164* <br /> SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464E <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 <br /> PIPING/LURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4_FIBERGLASS 0 10,RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) a64e. <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL :R 4.FIBERGLASS ❑ 10.RIGID PLASTIC Ll 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 464n <br /> VR PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4648 <br /> 464SI <br /> VR SECONDARY CONTAINMENT 0 1.STEEL JZ 4.FIBERGbM____0 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 464h <br /> VENT PIPING TRANSITION SUMP TYPE Q 1.SINGLE WALL X 2.DOUBLE WALL L1 90.NONE 464b)464E <br /> RISER PRIMARY CONTAINMENT IX 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99-OTHER(Specify) 4641 <br /> 464iRISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ) <br /> ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464E <br /> 464kl <br /> FILL COMPONENTS INSTALLED 1.SPILL BU5Eff_0 3.STRIKER PIATSMOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a� <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL <br /> ❑ 3.NO DISPENSERS ❑ 90.NONE 469* <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S eci ) 469bt <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and In full com liance with leol require <br /> PLICANT SIGNA DATE L,V O 470. <br /> APPLICANT NAME(print) 471' APPLICANT TITLE 472. <br /> s�.q,�1 P�7-,�iPS c3nF <br /> rip F ITRT_R-1/2 Rev_n 2/2n(IT <br />