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la.. ti! UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one hem only For a UST closure or removof.complete only this section amt Sections!,I!!!!,!V,and LYbe/aw) +s9 ❑ I.NEW PERMIT ❑ J.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION .TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8USTREMOVAL 1RH6 UST PERMANENTLY CLOSED: nos DATE EXISTING UST DISCOVERED: 43% L FACILITY INFORMATION MNAME gency Use Only) (Same as FacilityNome or DBA-Doing BusmessAs) 5 DDRESS 1m CITYa 88 Lockeford H. TANK DESCRIPTION TANK ID(t Ud TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS +s+ 3 STIP ® I.AST.AND-ALONE TANK Co�wlae on pyn forret EJ 2.ONE INA COMPARTMENTED UNIT <erp -wrMose DATE UST SYSTEM INSTALLED +55. TANK CAPACITY M GALLONS 030. NUMBER OF COMPARTMENTS IN THE UNIT +37 1990 10,000 1 III. TANK USE AND CONTENTS TANK USE 0 Is.MOTOR VEHICLE FUELING 0 Ib.MARINA FUELING ❑ le.AVIATION FUELING-439 ❑ 3.CHEMICAL PRODUCT STORAGE 0 3.HAZARDOUS WASTE(IwI Ura 011) ❑ 5.EMERGENCY GENERATOR FUEL1115C$25301 51c)1 ❑ 6 OTHER GENERATOR FUEL _ 0 95.UNKNOWN __ _ ❑ 99.OTHER(�iffk)_ ass. CONTENTS PETROLEVM: ❑ le_REGULAR UNLEADED 03 lc.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED uo ❑ J.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS 0 R PETROLEUM_BLEND FUEL__0 9 OTHER PETROLEUM(Spwty). u9° NON-PETROLEUM1I ❑ i.USED OIL r]-10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(specify: 4a9b. IV. TANK CONSTRUCTION TYPE OF TANK Q L SINGLE WALL 0 2.DOUBLE WALL Q 95.UNKNOWN r3 PRIMARY CONTAINMENT ® I.STEEL ❑ 1 FfBERGLASS D 6.INTERNAL BLADDER +ae 0 7.STEEL INTERNAL LINING 0 95.UNKNOWN _❑ 99 OTHER(Spec(fyl: u0a SECONDARY CONTAINMENT 0 I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 19 7.JACKETED us _____-,__,__ ____ 090.NONE 095.UNKNOWN 099.OTHER(Specifyy use OVERFILL PREVENTION 0 I AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 3.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E DIP,MENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1SINGLEWALL 9 2 DOUBLEWALL ❑ 99.OTHER ado. SYSTEM TYPE ® LPRESSU RE 0 2 GRAVITY 0 A CONVENTIONAL SUCTION ❑ d SAFE SUCTION[23 CCR IxwpRS)( s5i PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE 0 10.RIGID PLASTIC 4M 0 90.NONE ❑ 95.UNKNOWN [199.OTHER(Spenfy): SECONDARY CONTAINMENT ❑ I.STEEL ® d.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC +6ab 0._90.NONE _ ❑ 93.UNKNOWN _❑_99.0TFIER(_Spccdyy h4. P IPING/TURBINE CONTAINMENT SUMP TYPE 0 L SINGLE WALL 0 2.DOUBLE.WALL 0 90.NONE +6+a VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION RY CONTAINMENT 0 1.STEEL 0 a FIBERGLASS 0 10.RIGID PLASTIC 090 NONE ❑ W.OTHER(Specify l: d_ __. _DARY CONTAINMENT ❑ I STEEL 0 d FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 W.OTHER(Y CONTAINMENT ❑ I STEEL 0 4 FIBERGLASS 0 I0.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(ARY CONTAINMENT0 1 STEEL 0 4.FIBERGLASS 0 10.RIGIDPLASTIC 0 W NONE ❑ WOTHER(Speclfy)TRANSITION SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 9B.NONE d60i RISER PRIMARY CONTAINMENT ® I STEEL 0 d FIBERGLASS 0 10,RIGID PLASTIC ❑ 90 NONE 0 99 OTHER(Spwlfy): IZZI RISER SECONDARY CONTAINMENT 0 1 STEEL ❑ d.FIBERGLASS ❑ 10 RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify): a6a1e _ _ 6041 FILL COMPONENT$INSTALLED ® 1.SPILL BUCKET ® J.STRIKER PLATFIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP +5[°" VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1 SINGLE WALL ❑ 2.DOUBLE E WALL_ 0 i NODISPENSERS ❑ 90.NONE +09e CONSTRUCTION MATERIAL 0 L STEEL ❑ 3.FIBERGLASS 0 10.RIGID PLASTIC 0 W.OTHER(Specily) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) ❑ +.IMPRESSED CURRENT 0 6.ISOLATION ++s IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate.and in full compliance with legal requirements. APPLICANT SIGNATURE ( tck DATE 6/8/2009 4M APPLICANT NAME(print) Sandy E wards +71 APPLICANTTITLE Environmental Compliance 472 UPCF UST-8 Rev.(17/2007)-1/2 www.unidocs.org