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UNIFIED PROGRAM CONSOLIDATED FORM -� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(;JILTV, n Us TYPE OF ACTION (Check one item only. For an UST pc mmmt closme or removal-complr(a only this section and Secliom L H, std IX below11°❑ 1 NEW PERMIT 3.RENEWAL PERMIT 105CHANGE OF INFTION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED. 4104 DATE EXISTING UST DISCOVERED' 1. FACILITY INFORMATION 1 FACILITY ID R(AStney Use Only) _ - 5 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bmineas As) M M a BUSINESS SITE ADDRESS 105 CITY STuLKT.N 11.TANK DESCRIPTION TANK IDB p 41r TANK MANUFACTURER 455 TANK CONFIGURATION: THIS TANK IS 73-4 \ _ ❑I.A STANDALONE TANK (S L iz iS ❑2.ONE IN A COMPARTMENTED UNIT Co vn f«rd Ivm,wr DATE UST SYSTEM INSTALLED I55 TANK CAPACITY IN GALLONS '16 NUMBER OF COMPARTMENTS IN]TIE UNIT 437 1Z ,� 111.TANK USE AND CONTENTS TANK USE 5d Ia MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 49 ❑ 3.CHEMICAL PRODUCTSTORAGE ❑ a.HAZARDOUS WASTE Ndda Uwd UO [3 5.EMERGENCY GENERATOR FUEL IMC 125261.5(•11 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER( ): nw CONTENTS PETROLEUM: Cl Ia REGULAR UNLEADED IC MIDGRADE UNLEADED ❑ Ib.PREMIUMUNLEADED N9 [33.DIESEL 8 5.JET FUEL [16.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 139.OTHER PETROLEUM uoe NON-PETROLEUM:❑ ?.USED OIL ❑ 10.ETHANOL um IL OTHER NON-PETROLEl1M(S IV. TANK CONSTRUCTION TYPE FTANK 1.SINGLE WALL 2.DOUBLEWALL 95.UNKNOWN 465 PRIMARY CONTAINMENT ❑ I.STEL 1 3.FIBERGLASS U 6.IN TIRNAL BLADDER N.1 7.STEEL-INTERNAL LINING S.UNKNOWN 99.OTHER (S MI. SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑6.EXTERIOR d fy)b NE LINER 7.lACKEIED 465 ❑90.NONE [] 93.I1NKNOWN OTHER 15 use OVERFILL PREVENTION I.AUDIBLE d VISUAL ALARMB 2.8&"F6AT 3.FILL TUBE SHUT-OFF VALVE 452. ❑l TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ULSINGLE-WALLED 2.DOUBL6WALLED 99.OTHER 169 SYSTEM TYPE 1.PRESSURE 2.GRAVITY 3.CONVENTIONAL STICTION ❑ a.SAFE STICTION 25 CCR ju 4X3IM PRIMARY CONTAINMENT 1.51 L a.FIBERGLASS U 3.FLEXIBLE IO.RIGIDPLASTIC 0 0.NONE 95.UNKNOWN (] 99.OTHER(Soeofy):SECONDARY CONTAINMENT ISTEELa.FIBERGLASS 8.FLEMBLE 10.RIGID PLASTIC❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER( ):PBINGrruRBtNE CONTAINMENT SUMP TYPE ISINGLE WALL 2.DOUBLE WALL 9D.NONEVL VENT,VAPOR RECOVERY(VR)AND RISER/F ILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL a.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Speciry)VENT SOUNDARY CONTAINMENT 1.STEEL 1.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Spcfy)VR PRIMARY CONTAINMENT 1.STEEL a.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) VR SECONDARY CONTAINMENT L STEEL Ll a.FIBERGLASS 10.RIGID PLASTIC IM 90.NONE 0 99.OTHER(Specify) s6N a6Y1 VENT PIPING TRANSRION SIIMPTYPE 1.SINGLE WALL 2.DOUBLE WALL 0 W.NONE 464. RISER PRIMARY CONTAINMENT I.ST1Fl. /.FIBERGLASS 10.RIGID PLASTIC W.NONE E3 99.OTHER(Specifjr) 46« RISER SECONDARY COMAINMFNT IN1.STEEL a.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.UnIER(Specify) 4646 Ieekl FLLL COMPONENTS STALLED 1.SPILL BUCKET 0 3.STRIKER PLATESOITOM PROTECTOR 0 t.CONTAINMENT SUMP 461ac VIL UNDER DISPENSER CONTAINMENT(UDQ CONSTRUCTION TYPE ® 1.SINGLE WALL O 2.DOUBLE WALL 0 3.NO DISPENSERS ❑90.NONE 466 CONSTRUCTION MATERIAL 0 1.STEEL 11 4.FIBERGLASS 0 10.RIGID PLASTIC 99.OTHER S ) euEc VIN. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) ❑ a.IMPRESSED CURRENT (]6.ISOLATION w 61 VL APPLICANT SIGNATURE CERTIFICATION: 1 terdfy ten Is newith the hazardous substance stored and that the infarsmadaa prw ded herein is but.s ccarate, and la fd h n. APPLICANT SIGNATURE DAIS eco APPLICANT NAME(print) 971 1 APPLICANTTITLE 47 tj UPCF UST-111-In Rev.(IMM) Scanned by CarnScanner