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semi RECEIVEI. � UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK H_TH OPERATING PERMIT APPLICATION-TANK INFORMATIO Ht TYPE OF ACTION (Check one Rem only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,[It, en below) 610 ❑ ].NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGEOF INFORMATION 6.TEMPORARY UST CLOSURE. ❑ 7.UST PERMANENTCLOSURE ON SITE B.UST REMOVAL DATE UST PERMANENTLY CLOSED: OD. I DATE EXISTRJOUSTDISCOVEUI): 1306 L FACILITY INFORMATION 0,6d O FACILITY ID#(Agency Use Only)VA Ot�-03541 - 1 BUSINESSNAME(Same as FACILITY N7 rDBA-Doing Business As) ' mac/ e:n _SIL. o o :fr w r ft .Y1f 5�••1/S4ia� .s it q ✓r r• /ln�.fu.% BUSINESS SITE ADDRFS$ IDJ CITY 1 -_ 4 `f,! •le R•ee( eek a,n IL TANK DESCRIPTION TANK ID# 431 TANK MANUFACTURER 613 TANKwNFIOURATION:TMSTANKIS 434 ASTAND-ALONETANK 2.ONE IN A COMPARTMENTED UNIT dAn�tni44r n ~WA .",%N om waw» hrerh ulmm,fn 0u ode DATE UST SYSTEM INSTALLED 633 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 w (� �f L TANK USE AND CONTENTS TANK USE ❑ 1..MOTOR VEHICLE FUELING 0 Ib.MARINA FUELING ❑ Ic AVIATION FUELING 439 03.CHEMICALPRODUCT STORAGE ;K4.HAZARDOUS WASTE(MWU al) OS.EMERGENCY GENERATOR FUELINSC 4ssvlsh)1 ❑ G OTHER GENERATOR FUEL 0 95.UNKNOWN ❑99.OTHER(S 439. CONTENTS PETROLEUM: ❑ I..REGULARUNLEADED 0 I4.MIDGRADK UNLEADED ❑ Ib.PREMIUM UNLEADED MO [1 3.DIESEL ❑S.JET FUEL ❑6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL go 9.OTHER PETROLEUM S :G N C- 440. NON-PETROLEUM:PL 7.USED OIL [] METHANOL ❑ 11.0THERNON-PETROLEUM S eci : WE IV. TANK CONSTRUCTION TYPEOFTANK ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑95.UNKNOWN 643 PRIMARY CONTAINMENT ❑ LSTEEL ❑ J.FIBERGLASS 0 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING 093.UNKNOWN ❑ 99.OTHER (S ): Noe SECONDARY CONTAINMENT ❑ 1.9TEEL ❑'.FIBERGLASS 06.AMEMBRANE LINER ❑ 7.JACKE-TED a45 0 90.NONE 0 95.UNKNOWN ❑99.OTHER S ' b 445° TI OVERFILLPREVENON I.AUDIBLE&VISUAL AL ARMS ❑2.BALLFLOAT 3.FILL TUBS SHUT-OFF VALVE 45x. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Q LSINGLE-WALLED ❑7.1)OUBLE-WALLED .OTHER SYSTEM TYPE ❑ I.PRBSSURB ❑ 2.(IUV ❑ 3. NVENTIONAL SUCTION ❑ 4.SAFESUCTION F3 CCR 1206h)(3) 458 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.PIKER LASS 0 S.FLEXIBLfi ❑ 10.RIGID PLASTIC 464 0 90.NONE 0 95.UNKN WN 0 99.OTHERS i : 464a SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 8.FLfiXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN 099.OTHER S ): 461v PIPINGITURBINECONTATNMENT SUMPTYPE 01.3INOLEWALL 0 2.13OUBLEWALL 090.NONE 464a VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIUJUPLA511C W.NONE 0 99.OTHER(Speciry) 466 464e1 vmrsECONDARY CONTAINMENT I.STEEL [I 4.1`I1IERGLAS3 0 10.RIGID PLASTIC Ej WHORE_ 99.OTHER(Specify) 465P 464n VRPRIMARYCONTAINMENT 0 1.STEEL tj 4.FIBERGLASS "GID PLASTIC 090.NONE 99.OTHER(Specily) 46^8 464 1 VR SECONDARY CONTAINMENT Q LSTEEL 4.FIBERGLASS 0 I0.RIGIDPLASTIC 0 W.NONE 0 99.OTHER(Spwify) 4616 164x1 VENTPIPINGTRANSrf10N SUMPTYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 461E RISER PRIMARYCCa TAINMENT 1.STEEL 4.MEROLASS IO.RIOID PLASTIC Ll W.NONE u 99.01"HER(Speeify) 46 1 RI SER SECOTIDARYCONTAINMENT LSTEEL 4.PIBERGLAS3 10.RIGID PLASTIC W.NONE 99.OTHER(Spaify) 4Wk mi, FILL COMPONfiNTS INSTALLED LSPILL BUCKET 3.STRIKER PLATE,BOTfOM PROTECTOR 4.CONTAINMENT'SUMP 4sl.c VII.UNDER DISPENSER CONTAINMENT(UDC) - CONSTRUCTIONTWE 01.SING LB WALL 02.DOUBLEWALL ❑3.NODISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ :STEEL ❑ 4.FIBEROLASS ❑ IO.RIGIDPLAS-nC ❑99.OTHER ) 46964 VIN. CORROSION PROTECTION STEEL COMPONENT FROTEC170N ❑2.SACRIFICIALANODE(S) 0 4.IMPRESSED CURRENT ❑6.ISOLATION 448, M APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST em is com 'bie with the hazardous substance stared and that the Information provided herein is hue,accurate, ead in Tull e0 ee re meo _ 470. APPLICANT SIGNATU DATE APPLICANT NAME r..d - 941' A_PPLICANTTrrLE V M UPCF UST-B-12 Rev.(122007)