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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,II,III,IV,and IX below) 430 <br /> �� � I.NEW PERMIT El 3.RENEWAL PERMIT [115.CHANGEOF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4307 DATE EXISTING UST DISCOVERED: 430b <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> sA. rel oA 0 01N <br /> BUSINESS SITE ADDRESS 103 1 CITYS T 104 <br /> II.TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> �'�^�`� C C>N -rA I K M,F^17- On-A STAND-ALONE TANK <br /> OT;k S o(_V T 1 o h1 S ❑2.ONE IN ACOMPARTMENTED UNIT. <br /> Complete one a for each com went in me unit <br /> DATE UST SYSTEM INSTALLED 435 TANK C CITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 432 <br /> Z e Aq gal <br /> III.TANk USE AND CONTENTS <br /> TANK USE :ff 1a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(1.4.dm Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL(HSC P5281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑'95.UNKNOWN ❑ 99.OTHER(Specify): 439s <br /> CONTENTS PETROLEUM: 0 Is.REGULARUNLEADED ❑ la MIDGRADEUNLEADED ❑ ]b.PREMIUM UNLEADED 440 <br /> 0 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM Sec' 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL $ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL J9 3.FIBERGLASS 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER57.JACK444a <br /> SECONDARY CONTAINMENT El 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ETED 445 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Speci 44511 <br /> IERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 02.13ALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑2.DOUBLE WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION R3 OCR 42636(a)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464■ <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TU'RBINECONTAINMENT 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 1.STEEL ® 4.FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a64e <br /> 464.1 <br /> VENT SECONDARY OONTAINMINT ❑ 1.STEEL JD 4.FIBERGLASS ❑ 10.RIGID PLASTIC U 90.NONE ❑ 99.OTHER(Specify) 464[ <br /> 464 fl <br /> VR PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC Ll 90.NONE 99.OTHER(Specify) 46411 <br /> 1 <br /> VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS Ll 10.RIGID PLASTIC 90.NONE 0 99-OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2,DOUBLE WALL 90.NONE 4647 <br /> RISER PRIMARY CONTAINMENT t.STEEL 4.FIBERGLASS L1 10.RIGID PLASTIC 90,NONE 99.OTHER(Specify) 4641 <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464kl <br /> FILL COMPONENT'S INSTALLED 05 1.SPILL BUCKET 3.STRIKER PLATE IBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 45111 <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46911 <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 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 compliance with legal require <br /> PLICANT SIGNA DATE 470. <br /> APPLICAqT NAME(print) Q� � 1121. 472. <br /> 0� APPLICANT TITLE <br /> T TVrV TTCT_R-It2 Rev.112/200'n <br />