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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION low formper UST) TYPE.OF ACTION (Check one item only. For an UST permanent clwwe or mronvd,comem onlyplthu aOcUon and Seetions 11 11,III,IV•and IX below) TNI ❑ I NEW PERMIT 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 6 TEMPORARY UST CLOSURE 7.USTPERMANENT CLOSURE ON SITE B.UST REMOVAL rwe DATE UST PERMANENTLY CLOSED 40. 1DATE EXISTING UST DISCOVERED 1. FACILITY INFORMATION 1 FACILITY ID p(Agrnry Un Only/ - - BUSINESS NAME(Same as FACILITY NAME or DBA-13=9 Bmirm Aa) a BUSINESS SITE AD RESS lot CITY S i GKwN 11.TANK DESCRIPTION TANK ID p 439 TANK MANUFACTURER 411 TAWcoVPGUMAUON:THISTANK IS r>. Q ®1 A STAN6ALONE TANK ❑2.ONE M ACOWARTMFNTFD UNIT. C r h.tl nAs As. X17 DATE UST SYSTEM INSTALLED 411 TANK CAPACITY IN GALLONS 4N NUMBER OF COMPARTMENTS IN THE UNIT 111.TANK USE AND CONTENTS Us TANK USE ® Ia MOTOR VEHICLE FUELING CI b.MARINA FUELING O Ic AVIATION FUELING 0.CHEMICAL PRODUCT STORAGE 0.HAZARDOUSWASTE 11.du1e tN,d al 03.FMEAGENCYGENFRATOR FUEL IW p73n131g1 3a 0 6.OTHER GENERATOR FUEL [U3 95.UNKNOWN 0 99.OTHER( ): 40 CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED O Ic.MIDGRADE UNLEADED IS Ib.PREMIUM UNLEADED ❑ 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS ❑ 6.PETROLEUM BLEND FUEL ❑9.DIETER PETROLEUM (Sold uo, NON-PETROLEUM: 7.USED OIL 0 10.Ef}IANOL 3rA 11 OTHER NON-PETROLEUM(S IV. TANK CONSTRUCTION TYPE OF TANK 01 SINGLE WALL 2.DOUBLE WALL 095.UNKNOWN 41 PRIMARY CONTAINMENT I.STEEL ® 3.FIBERGLASS 6.INTERNAL BLADDER 44 T STEEL+INTERNAL LINING 095.UNKNOWN ❑ 99.OTHER 444 SEC ONDARYCONTAINMENT I.STEEL 3.FIBERGLASS 6.EXTERIORMEI.03RANE LINER 7.lACKEfED ws 90.NONE ❑ 95.UNKNOWN 99.OT51ER( 44 OVERFILL PREVENTION I.AUDIBLEd VISUAL ALARMS 2.BALL FLOAT I.FW.TIP3E SFM-0FP VALVE 451 0 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPA4NT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED 2.D011BLE-WALLED 99.G5HER 0pO PIPING CONSTRUCTION TYPE 1.PRESSURE 2.GRAVITY 3.CONVENTIONAL SUCTION 4.SAFE SUCTIONIUZai2'W-X31 459 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS I.FLEXIBLE 10.RIGID PLASTIC 16. ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OlIIFR(S 1: 161, SECONDARY CONTAINMENT 1.STEEL 1.FIBERGLASS 0 e.FLEXIBLE 10.RIGID PLASTIC 4616 N ❑ 90.NONE 0 95.UNKNOWN 0 99.OTHERS Y 4Ae PIPINGrRBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOlIBLE WALL 90.NONE 46i1 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC u90.NONE 99.OTHER(SpcciH) 4444 ra41 VENT SECONDARY CONTAINMENT 1.STFFL 1.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER($Pacify) 4arm 6N VR PRI ARYCONTAINMENT 1.STEEL 1.FIBERGLASS 10.RIGID PLASTIC 90.NONE M99.OTHER(Specify) µ1 VR SECONDARY CONTAINMENT 1.STEEL /.FIBERGLASS 10.RIGID PLASTIC M 90.NONE edfy) 99.OTHER(SpA6N IaYI VENT P%NG TRANSITION SUMO TYPE 1.SINGLE WALL 2.DOUBT-E WALL 90'NONE bl' RISER PRIMARY CONTAINMENT I.STFEL /.FIBERGLASS 10.RIOID PLASTIC 90.NONE 99.ODB3RR(Specify) ray RISER SECONDARY CONTAINM@TT 1.$TEA l FIBERGLASS 10.RIGID PLASTIC 0 90.NONE F3 99.OTHER(Specify) r65k 1l FILL COMffONEF1T5 INSTALLED 10 I.SPILL BUCKET a 3.STRIKER PATEBOTOM PROTECTOR 0 I.CONTAINMENT SUMP 451.s VU.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOl1BLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 169' CONSTRUCTION MATERIAL 1.STFFL /.FIBERGLASS 10.RIGID PLASTIC 99.DIETER ) 4196a VIII. CORROSION PROTECTION STEEL COMPONENT pROlECI10N0 2.SACRIFICIAL ANOORS) 01.IMtPRESSEDCDRRENT U ISOLATION W IX PLICANT SIGNATURE CERTIFICATION: 1 tertlfy tYb Y c 0 tl fee famume alarmed end that the iafarsnatloa Provided berets Is tree.accente, and in tam oce I rA. APPLICANT SIGNATURE DATE B 471_ APPLICANT TITLE AAty 1�. APPLICANT NAME(prior) /V Ci r'- UPCF VST-9-1R Rev.( z"r) Scanned by CamScanner