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"IFIED PROGRAM CONSOLIDATED FO. UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One fM U$T) EI INEW PERMIT TYPE OF ACTION (Check one item only. For o UST closure or removal,romplete only Z"-.1'.and Sections I(/!f1 IV and IXbelaoDnw) 410 . ❑ 3.RENEWAL PERMIT 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE ® 5.CHANGE OF INFORMATION DATE UST PERMANENTLY CLOSED: 8.UST REMOVAL °30i DATE EXISTING UST DISCOVERED: 41x6 FACILITY IDM(Agency I. FACILITY INFORMATION Use Only) BUSINESS NAME(Samr as Facility Now or DBA-Doing Burw"As) ShelVresoro 68150 3 BUSINESS SITE ADDRESS 103 CITY 13975 E. Hiwa 88 Lockeford IN II. TANK DESCRIPTION TANK ID it a-' TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK I$ 414 STIP ® 1.A STAND-ALONE TANK Co Tem.Peae f«ecce DATE UST SYSTEM INSTALLED 435 2.ONE INA COMPARTMENTED UNIT me a.t in me unn TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. 19% 10,000 1 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE O 4.HAZARDOUS WASTE(I.I.dm Umi a0 0 5.EMERGENCY GENERATOR FUEL HSC ❑ e.OTHER GENERATOR FUEL 0 95.UNKNOWN [ 415u15(c)) CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED .OTHER( i ): a4 ❑ I Dmcc• ❑ Ic.MB7GRADE UNLEADm Ib. UNLEADED 440. ❑ 5.JET'FUEL A ❑ 8.PETROLEUM BLEND FUEL 0 9.OTNER PETROLEUM(S ): 440e NON-PETROLEUM: 7.USED OIL 10.ETHANOL - ❑ 1 L OTHER NON-PETROLEUM(S if: IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2,DOUBLE WALL 0 95.UNKNOWN „3 PRNMYCONTAIN Nf - _ ._ ---- ----..- . ® 1.STEEL ❑ 3.FIBERGLASS 0 6.INTERNAL BLADDER 0 7.STEEL°INTERNAL LINING ..._ 093.UNKNOWN ❑ 99 OTFffR(Spey-y)' 444 SECONDARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LIFTER ® 7.JACKETED M5. 0 90.NONE _ O 95.UNKNOWN_ 0 99.OTHER(Specify) Nk OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ L.BALL FLOATRg 3.FILL TUBE SHUT-OFF VALVE 432. 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 I SINGLE WALL 0 2.DOUBLE WALL 0 99.OTHER __ 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4 SAFE SUCTION[aJ CCa f26.i6(eXJI) 4u. PRIMARY CONTAINMENT 0 1.STEEL 10 4.FIBERGLASS ❑ 8.FLEXIBLE O 10.RIGIDPLASTIC 464 O 9o.NONE 0 95.UNKNOWN 0 ".OTHER( ifyp 464 SECONDARY CONTAINMENT 0 1.STEEL 0 4 FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 O 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Speciry): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE W I.SINGLE WALL 0 2.DOUBLE WALL 0 90,NONE 4sW. VI. VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 464 --.._.-__._-6-4- __ Wbl_ VEIN'SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTIIDIt(Speeiry): 461 4411 VR PRIMARY CONTAINMENT 0 I,STEEL 0 4.FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE 0 ".OTHER(specify): 4641. VR SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ® 90.NONE 0 99.OTHER(specify): 461h1. VENT PING TRANSITION SUMP TYPE 0 I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE �. RISER PRIMARY CONTAINMEM' ® L STEEL O 4.FIBERGLASS O 10.RIGID PLASTIC ❑ 90,NONE 0 99.OTHER(Spre*): 464)). 464'I. RISER SECONDARY CONTAINMENT 0 1.STEEL O 4.FIBERGLASS O 10.RJGID PLASTIC ® 90.NONE 0 ".OTHER(Specify). FILL COMPONENT$INSTALLED ® i.SPILL BUCKET ® 3. 4 STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 43111 VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL O 2,DOUBLE WALL [3 3.NO DISPENSERS 0 90.NONE 464• CONSTRUCTION MATERIAL ® EL I.STE0 4.FIBERGLASS O 10.RIGID PLASTIC O 99.OTHER(Specify) ..... +i6a99' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ® 2.SACRIFICIAL ANODE(S)S) 0 4.IMPRESSED CURRENT 0 6.ISOLATION Me. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the bs=rdous substance stored and that the informadon Provided herein is true. accurate and in full coon Iance with 1 al r utremenb. APPLICANT SIGNATURE C' �S DATE 4/28/2011 4'0 APPLICANT NAME(print) that E wards "' APPLICANT TITLE Environmental Compliance °'�- UPCF UST-B Rev.H=W7)-112 www.unidocs.org