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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form a UST) -TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section end Sxtions I,I),131,IV,mid IX below) 430 ❑ LNEW PERMIT ® 3.RENEWAL PERMITS.CHANGE OF INFORMATION 6.TEMPORARY USTCLOSURE 7.UST PERMANENTCLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 I DATE EXISTING UST DISCOVERED: /'}yS aob FACILITY ID M(Agency Uxe OI. FACILITY INFORMATION nly) - _ _ r BUSINESS NAME(Semens FACILITY NAME or DBA-Doing Business As) 3 La/ a -S7'44k o s :lri w e kfe2a14 4 Si.></Sf o f a .r iir✓. BUSMF5S3 SfTE ADDRFS 103 /MN QI/we�FYii/. CITY Z eii Ax R..e/ .e% �n 11.TANK DESCRIPTION TANK[DN 433 TANK MANUFACTURER 433 TANKCONFlGURATION:THIS TANK IS 434 �Ir�{'rr1 A STAND-ALONH TANK !!,�, y a.�4.44y LJ 2.0NEINACOMPARTMENTED IINTf \3 DATE UST SYSTEM INSTALLED 433 x. rosone ror erh lin tla �`.: TANK C FAVI lM r.A r r new 436 NUMBER OF COMPARTMENT$. IT w e ' III.TANK USE AND CONTENTS 03.CHEMICAL PRODUCTSTORAGE > +. TANK USE 0 RYEHICLEFUELNG 0 lb.MARINA FUELING O Io.AVIATION FUELING ,g,4.HAZARDOUS WASTE prrcl U OTO 05.EMERGENCY GENERATOR r15341.5(.)] 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99,OTHER(S ): ! 419E CONTENTS PETROLEUM: 0 Is.REGULAR UNLEADED ❑ Ie MIDGRADfi UNLEADED ❑ Ib.PREM111M UNLEADED mo 0 .I.DIESEL 0S.IET FUEL 0 6.AVIATION GAS 08.PETROLEUM BLEND FUEL 9.OTHERPETROLEUM 3 i 0"4114 ,h T'Fr.,a- f.�F 490E NON-PETROLEUM:p,7.USEDOIL ❑ 10.ETHANOL ❑ 11.OTHER HON-PETROLEUMS i 44ob IV. TANK CONSTRUCTION TYPEOF TANK ❑ I.WNOLEWALL 02.DOUBLEWALL 095.UNKNOWN N3 PRIMARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.INTERNAL BLADDER H4 07.STEEL+INTERNAL LINING 095.UNKNOWN SECONDARYCONTAINMENT 0 LSTEEL ❑ 99.OTHER (S 411E ❑3.FJ 6.EXTERIOR MEMBRANE LINER U 7.JACKETED a5 ❑ 90.NONE ❑ 95.UNKNOWN 099.OTHER 3 i : H5a OVERFILLPREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCE/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01.SNGLE•WALLED 02.DOUSLE-WALLED 1199.OTHER y9 SYSTEM TYPE 0 LFRESSURE 0 2.GRAMy 0 3.CONVENTIONALSUCrioN ❑ 4.SAFE SUCTION CCR 63536( ) 453 PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 Cl 90.NONE 0 95.UNKNOWN 0 99.OTHER(S ): 464a SECONDARY CONTAINMENT ❑ L STEEL 0 C FIBERGLASS 0 8.FLEXIBLE 0 I0.RIGID PLASTIC 4646 . 0 90.NONE 095. NOWN 0 W.OTHER(Specify): 4Nc PINNUiTURBNE CONTAINMENTSUMP TYPE 01.SING LE WALL 02,DOUBLE WALL ❑90,NOHE 464d VI.VENT.VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LSTEEL U -.FIBERGLASS U 10.RIGID PLASTIC El 90.NONE 99.OTHER(Specify) 464v VENT SECONDARY CONTAINMENT0 I.STEEL -.FIBERGLASS 10.RIGIDPLASTIC 90.NONE W.OTHER(Speeify) 44Wf VRPRIMARV CONTAINMENT 0 1,STEEL Ll 4.FIB 1:71 x 0.RIGID PLASTIC 4Un 90.NONE 99.OTHER(Specify) VR SECONDARY CONTAINMENT ❑ LSTEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h VENT PIPING TRANSrTiON SUMP TYPE I.SINGLE WALL 464hr 2.DOUBLfi WALL 90.NONE 460. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS IO.RIGID PLASTC 90.NONE 099.OTHER(Sp if)-4"j RISER SECONDARY CONTAINMENT LSTEEL 4.FIBERGLASS 10.RIGID PLASTIC90.NONE W.OTHER(Sp ify) 4e Wk FILLCOMPONENTSINSTALLED 1.SPILL BUCKET C1 3.STRIKER PLATEBOTTOMPROTECTOR 4.CONTAINMENTSUMP 4w VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 3.NO DISPENSERS 0 .90NONE 469• CONSTRUCTION MATERIAL 1.STEEL U 4.FIBERGLASS 0 10.RIGH PLASTIC 099.OTHERS ) 4696-c VDI. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) 114.IMPRESSED CURRENT 0 6.ISOLATION aa. LY. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the ham3rdou substance stored and that Me Informati.-provided herein to Trot eeeunte, aM In full com H 'th I 11'l7aents APPLICANT SIGNATURE DATE / �-/j. na APPLICANT NAME(p9pO �- .7- APPLICANT APPLICANT TITLE nz �GH ✓Q /�77.✓c�e�iY-L *- UPCF UST-B-12 Rev.(122007)