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I FIED PROGRAM CONSOLIDATED FOF ec UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- TANK INFORMATION (one form per UST) Iy1N TYPE OF ACTION /Check one item mdy. For o UST c(osure or removal,compfere onfy this section and Sections//l.//(, !{;a5d IX bel") 450 ❑ i.NEW PERMIT ❑ 3,RENEWAL PERMIT 6."TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE ® 5.CHANGE OF INFORMATION DATE.UST PERMANENTLY CLOSED: ON 8.UST REMOVAL DATE EXISTING UST DISCOVERED: 43W FACILITY IDN(AI. FACILITY INFORMATION gency L'se pn(Yl BU - - E(Some as Faclfiry'Name or DBA-Doing Business As) heWT o' 6blsu SS SITE ADD REss U5 CITY 13975 E. Hiwa 88 Lockeford M U. TANK DESCRIPTION TANK ID q 453 TANK MANUFACTURER ^» TANK CONFIGURATION:TH{STANK IS 4u. i' -�A v 10'3- STIP ® L A STAND-ALONE TANK DATE UST SYSTEM INSTALLED 4552.ONE INA COMPARTMENTED UNIT sveg9mnn ie tM otic TANK CAPACITY IN GALLONS 454 NUMBER OF COMPAR IMEN 15 IN THE UMT 437 1990 10,000 1 III. TANK USE AND CONTENTS TANK USE ® Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 13 3.CHEMICAL PRODUCT STORAGE ❑ AVIATION FUELING a9 ❑ 4.HAZARDOUS WASTE Urd aO ❑ S.99.OTHGENCYify): TOR FUEL(NSC 425za1 s(43i ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): a]9s CONTENTS PETROLEUM: ® Is,REGULAR UNLEADED ❑ IC.MIDGRADE UNLEADED ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS [3S.PETROLEUM BLEND FUEL _❑ 9.OTHER PETROLEUM(Specify): 4pe NON•PETROLEUM:� 7.USED OIL 10.ETHANOL ❑ I I.OTHFJi NON-PETROLEUMS i soy IV- TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 93 UNKNOWN s45 PRIMARY CONTAINMENT ® 1_STEEL ❑ J.FIBERGLASS ❑ 6.INTERNAL BLADDER a4n ❑ 7.STEEL+INTERNAL LINING E395.UNKNOWN C399.OTHER(Specify); NN. SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EMERIOR MEMBRANE LINER ® 7.JACKETED M5 ❑ 90.NONE ❑ 93.UNKNOWN ❑99.OTHER(S ifyl' 445. OVERFILL PREVENTION ❑ I.AUDIBLE 8 VISUAL ALARMS Q 2.BALL FLOAT ® 3.FILL TUEE SHUT-OFF VALVE 452 4.TANK MEETS RE UIREMENTS FOR E.KEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PB'ING CONSTRUCTION ❑ L SINGLE WALL ® 2.DOUBLE WALL ❑_99.OTHER 440. SYSTEMPRESSURE_ ❑ 2.GRAVITY ❑ S.CONVENTIONAL SUCTION ❑ 4.SAFESUCTION DCCR126J4(4XJ) 459. PRIMARY CONTAINMENT ❑ I.STEEL ® J.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 444 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ily): nos. SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 6446 ❑ 90.NONE - 093.UNKNOWN ❑ 99,OTHER(Specify)_ 4M4 PIPINGlR1RBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE W ALL ❑ 90.NONE VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® I.STEEL ❑ J.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify): VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ a.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Spectly): 4taf VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FlBEROLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4649 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4�ay4e VENT PIPING TRANSITION SUMP TYPE ❑ I,SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4445' _ 444 1 RISER SECONDARY CONTAINMENT (3 L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Spxify): 444t1 FILL COMPONENTS INSTALLED ® i.SPILL BUCKET ® 3.STRIKER PLATUBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 6519<. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1:SINGLE WALL _ ❑ 2.DOUBLE WALL _ ❑ 3.NO DISPENSERS 0 9(.NONE CONSTRUCTION MATERIAL, ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) s46646 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ® 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRFNT ❑ 6.ISOLATION 4.9. 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, seconte,and in full compliance with legal requirements. APPLICANT SIGNATURE. 1� DATE 12/1/2010 470 APPLICANT NAME(print) Sandy Ed ard5 1 nn APPLICANTTITLE Environmental Compliance 492 UPCF UST-B Rev.(128667)-1/2 www.unidocs.org