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I UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(Ona fo m r UST) TYPE OF ACTION (Check one item only. For UST permanent closure or removal,complete only this section and Sectiom I,II,III,IV,end IX below) 410 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE, 7.UST PERMANENT CLOSURE ON SITE MS.USTREMOVAL . DATE UST PERMANENTLY CLOSED: as DATE EXISTING UST DISCOVERED: /e:Ip ./y 4506 I. FACILITY INFORMATION FACILffY IDH(Agency Use OrclyJ _ 1 BUSINESS NAME(Same ns FACILITY NAME or DBA-Doing Busin=As) 3 cc& u -Sto-f� o s : . w r }•fa'R•{t 4 SIS/�Sfae�>:n it ii •/r r'. /�.•e.Fi..'/, BUSINESS SITE ADORES l03 CITY l //w.; .re R•.e/ raele 2irs U.TANK DESCRIPTION TANK IDH v2 TANK MANUFACTURER 455 TANK CONFlOURATION:TIOSTANKIS 454 1.A STAND-ALONE TANK Lew/Fw14r 2.ONE M A COMPARTMENTED UNIT. irl4Nh Co Ina one Porerh c•m lin We wlc DATE UST SYSTEM INSTALLED 455 TANK CAPACITY IN GALLONS 456 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANKUSE ❑ I.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING Q Ic.AVIATION FUELING 439 Q 3.CHEMICAL PRODUCT3TORAGE ,n,4.HA]ARD0USWASTEOntle4nL Qj) QS.EMERGENCY GENERATOR FUEL mcSssvl.s(q] Q 6.OTHER GENERATOR FUEL Q 95.UNKNOWN ❑ 99,OTHER(Specify): 459• CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ia MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 440 Q 3.DIESEL ❑ 5.JET FUEL Q6.AVIATION GAS Q S.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM :(( OlN (L 4eo4 NON-PETROLEUM:Qj,T.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM 3 4496 IV. TANK CONSTRUCTION TYPE OF TANK ❑ LSINCLEWALL ❑ 2.DOUBLEWALL U 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ i.STEEL Q 3.FIBERGLASS [16.INTERNAL BLADDER 414 Q 7.STEEL+INTERNAL LINING Q 95.UNKNOWN 0 99.OTHER (S y. 44ea SECONDARY CONTAINMENT ❑ ..STEEL Q3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ T.IACKIMD 445 Q 90.NONE ❑91.UNKNOWN 11".OTHER(S i 449 OVERFILL PREVENTION (,AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBESHUT-OFF VALVE 452 Q 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01.SINGLE-WALLED Q2.DOUBLE-WALLED Q99.OTHER 46e SYSTEM TYPE Q I.PRESSURE ❑ 2.URAVIIY ❑ 3.CONVENUONALSUCTION Q4.-SAFESU-nONW=&m6(40)I 458 PRIMARY CONTAINMENT Q I.STEEL ❑ 4.FIBERGLASS ❑ a.FLEXIBLE ❑ I0.RIGID PLASTIC 464 Q%.NONE Q 95.UNKNOWN 11919.OTHER(Speei ): 464• SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS Q S.FLEXIBLE Q to RIGID PLASTIC 164b 1190.NONE Q 95.UNKNOWN Q 99.OTHER(Speciy): 46 PIPINOffURBINE CONTAINMENT SUMPTYPE ElLSINGLEWALL Q2.DOUBLE WALL U W.NONE 4Md VI.VENTS VAPOR RECOVERy(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT (.STEEL QI.fIBERGLASS ❑ Ia.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 461e VENT e42SECONDARY CONTAINMENT LSTEEL ❑4.FIBERGLASS iD.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 461f .61n V0.PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS IO,RIGID PLASTIC 90.NONE 0 99.OTHER(Spmiy) 4619 161 1 VR SECONDARY CONTAINMENT D I.STEEL E3 4.FIBERGLASS 0 10.RIGID PLASTIC LI 90.NONE C199.OTHER(Speciy) 4Rh 46161 VEN PIPING TIUNSRION SUMPTYPE I.SINGLE WALL 2.DOVBLE WALL 90.NONE 4"L RISER PRIMARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS Cl 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Spaiy) 461j 46f 1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE 99.OTHER(Speciy) e61k essId FILL COMPONENTS INSTALLED L SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE Q 1.SINGLE WALL Q 2.DOUBLE WALL Q 3.NO DISPENSERS ❑90.NONE 469• CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS Q 16.RIGIDPLASTIC [3 99.OTHER(S ) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) Q 4.IMPRESSED CURRENT Q 6ASOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein Is tree,accurate, sod In full compliance with legal requirements. APPLICANT SIGNATURE DATE4M y-/y APPLICANT NAME(Pr' ) 011. APPLICANTTITLE 471. UPCF UST-B-IR Rev.(12200