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.f UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One farm per U5T) TYPE OF ACTION (Check ane item only. Foran UST permanent closure or removal,complete only this section and Section I,II,RI,IV,and IX below) a0 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE ❑ 7.USTPERMANENTCLOSUREON SITE XS.USTREMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTINGUSTDISCOVERED: /-?--IS 4506 I. FACILITY INFORMATION -rA D 5;?-o774 1+5 / q FACILITY ID#(Agency Use Only) P ' ? _ _ _ t BUSINESS NAME(Same n FACILITY NAME or DBA-Doing Businass As) JJ 5 Cs/If u -Sfe4a O i i i e n r tk 9 SI. BUSINESS SITE ADDRES 103 -- .Zsli If 4• Reel CITY 14C� �n e I II.TANK DESCRIPTION1V tn"11W TANK ID# 413 TANK MANUFACTURER 433434 T�$ANK CONFIOIIRATION: I _ �r ` ❑2.LA 0 ENA-COMPARTMENTED UNR. ddn/aMJ✓ n es0 Gmlr4eone rtrndla 3mdawh N 9 DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN 061 I nu9 06 NUMBER OF COMPARTMENTS IN THE UNIT =37 III.TANK USE AND CONTENTS I V A,TANK USE ❑ Ia MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ Ie.AVIATION E6 439 ❑3.CHEMICAL PRODUCT STORAGE ,;KMIAZARDOUSWASTEOndndn Umd OPO ❑ S.EMERGENCY OE)-IERATOR FUEL WSC IISnI.HcB [16.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ MOTHER(S ): 43% CONTENTS PETROLEUM: D In.REGULAR UNLEADED ❑ 1..MIDGRADS UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ &.AVIATION OAS [I B.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM 5 4ai 1, O/L/Le A TsrA mya 44a NON-PETROLEUM:19,7.USED OIL ❑ 10.ETHANOL ❑ II.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPEOFTANK ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 441 PRIMARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL♦INTERNAL LINING ❑95.UNKNOWN ❑ 99.OTHER (S ' 444. SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE (]95.UNKNOWN ❑99-OTHER S i 445• OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS 2.BALLFLOA 3.FILL TUBBSHUT-0FP VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ❑I.DOUBLE-WALLED ❑99.01IIER 469 SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION III CCR 12m6(•XI)I 453 PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE ❑ 10.RIGID PLASTIC 464 EI 90.NONE Cl 95.UNKNOWN ❑ 99.OTHER($ecify): 454^ SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ B.FLEXIBLE ❑ IO.RIOIDPLASTIC / b s ❑ 90.NONE .❑ 95.UNKNOWN ❑ 99.OTHER(S ): 4". PIPINOfTURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FIILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT ❑ LSTEEL ❑4.FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 90.NOE 99.OTNER(SPecity) 4&4e 464.1 VENT SECONDARY CONTAINMENT ❑ LSTEEL ❑4.FIBERGLASS ❑ IO.RIGID PLASTIC ❑ 9D.NONE 99.OTHER(Specify) 4641 4u0 VRPRIMARYCONTAINMENT ❑ LSTEEL 4.FIBERGLASS 0 10,RIGID PLASTIC ❑ %.NONE 0 99.OTHER(Specify) 'IM-9- ,164,1 649464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ W.NONE ❑ W.OTHER(Spocify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE D I.SINGLEWALL 0 2.DOUBLE WALL 0 90.NONE 4Mi. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ IO.RIGIDPLASTIC U 90.NONE ❑ 99.OTHER(Specity) 4"i 461 1 RISER SECONDARY CONTAINMENT Q I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE ❑W.OTHFR(Spmify) 4Wk 46 1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET U 3.STRIKER PLATEJBOTTOM PROTECTOR 4.CONTAINMENT SUMP 431.-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL - ❑ 2.DOUBLEWALL ❑ 3.NO DISPENSERS ❑ 90.NGNE 469. CONSTRUCTION MATERIAL LSTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ) 469 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT ❑6.ISOLATION - Ni UG APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardon suhstance stared and that the information provided herein is truc6 accurate, and in fell eon 1 Ihl eon APPLICANT SIGNAN DATE p 47M (p ,mac' APPLICANT NAMErjry)�GN�"�7 u� �� 0i1 APPLICANTTTIITLE 4T UPCF UST-B-1/2 Rev.(I L7007)