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UNIFIED PROGRAM CONSOLIDATED FORM L" UNDERGROUND STORAGE TANK (t�e OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 43" ❑ 1 NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ b.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 471 j DATE EXISTING UST DISCOVERED 430b 1. FACILITY INFORMATION _ FACILITY 1D 4(Agenry Lyse Only) _ BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) S-*T A O' • 7-j-957 BUSINESS SITE ADDRESS 103 CITY II.TANK DESCRIPTION TANK TD# ( 432 TANK✓MANUFACTURER 433 TAbjK CONFIGURATION:THIS TANK IS 434 A STAND-ALONE TANK ❑2.ONF.IN ACOMPARTNIENTED UNIT. 'TAp D��N Com ne one a a I'or each wm artm nl m the mail. DATE UST SYSTEM INSTALLED 411 TANK CAPACITY IN GALLONS 4j6 NUMBER OF COMPARTMENTS IN THE UNIT 43' d t Q 11 ovo `y III.TANK USE AND CONTENTS TANK USF LL MOTOR VEHICLE FUELING ❑ ib.MARIKA FUELING ❑ Ic.AVIATION FLIELP40 U9 ❑ 3 CHEMICAL PRODUCT STORAGE ❑4.14AZARDOUS W.ASTEUn.ludmtJsedOil) ❑ 5.EMERGENCY GENERATOR FUEL IHSCt25281.51ep ❑ 6 OTHER OFNERATOR FUEL ❑95.UNKNOWN ❑ 99.OTHER (Specify)i: 41%% CONTENTS PETROLEUM: CU Ia.REGULAR UNLEADED ❑ 1c.VIIDGR.ADEUNLEADED ❑ Ib PREMIUM UNLEADED J4c ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S ecir•): NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OT14FR NON-PFTROLEUM S 'fv): 41.11 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑95.LNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 _ ______❑ 7.STEEL-INTERNAL LINING ❑95.L NKNO%VN ❑ 99.OTHER (Specify): 44-U SECONDARYCONTAIN\.FNT ❑ 1 STEEL JK 3.FIBERGLASS ❑ 6.EXTERIOR riFmBRANELINER ❑ 7.JACKETED W ❑ 90.NONE ❑ 95.UNKNOWW ❑99.OTHER(Specify): 4453 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS go 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONS7RLCT10N ❑1.SINGLE-WALLED IC2.DOUBLE-WALLED n 99.OTHER 4f4' SYSTEM TYPE Ga 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SL:CTION ❑ 4.SAFE SUCTION 123 CCR 5263QcX3)I 45R PRIMARY CONTAINfvILNT ❑ 1.STEEL. X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ ID•RIGID PLASTIC 4f`I ❑ 90.NONE. [ 95.UNKNOWN ❑ 99.OTHFR(Specify): 4" SECONDARY CONTAINVIENT ❑ 1.STEEL K 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4f.tc PIPt'A il1RBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL N 2.DOUBLE WALL _❑ 90.NONE 4414 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY C'ONrf 41ti.M,ENT Lj I.STEEL V 4.FIBERGLASS D 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) _W4w 4(rle l VENT SECOND:\R1'CONTAINN(E-NT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC CI 90.NONE ❑ 99.OTHER(Specify) 4fi1f waft VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE 99.OTHER(Specify) 4i�itt VR SECONDARY CONTAINNIENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h UA I VENT PIPINGTRANSXION SLAP TYPE ❑ I.SINGLE WALL CZ2.DOUBLE WALL ❑ 90.NONE 464i RISER PRIMARY CONTAINNIENT ❑ 1.STEEL K4-FIBERGLASS ❑ to.RIGID PLASTIC Lj 90.NONE ❑ 99.OTHER(Specify) 4641 4(411 RISER SECONDARY CONTAINMENT 1.STEEL U&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTI•TER(Specify) 464k 4&411 FILL COMPONENTS INSTALLED Iff I.SPILL BUCKET Xr3.STRIKEPPLATF.BOT70NIPPOTECTOR W4.CONTAINMENTSUmP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 404 CONSTRUCTION MATERIAL ❑ L STEEL P&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL CONIPONENT PROTECTION SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44x IX. APPLICANT SIGNATURE _ CERTIFICATION: I certify that his UST system is compatible with the hazardous substance stored and that the information provided herein is true,Rerur.ate. and in fu 11 compliance with legal requirements. APPLICANT SIGNATURE DATE APPLICANT NAME(prim; 471. APPLICANT TITLE 47` IIPCF UST-B-1/2 ;. ' ' Sm.(12r2007) V d LOZZ-991V-60Z 141AA OOUEUMB= d/tb 90 60 LZ UE`