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o . <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (one form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,it,III,IV.and IX Wavv) 430 <br /> ❑ I.NEW PER-MIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE Ej S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43ia 1 DATE EXISTING UST DTSCOVERED: Oft <br /> - -� I. FACILITY INFORMATION <br /> FACILITY ID p Wgeni7v Use OnitJ <br /> BUSINESS NAME(Same as FACTLTTY NAME or DBA-Doing Business As) 1 <br /> S-TAt 87 .157 <br /> BUSINESS SITE ADDRESS 103 CITY lo' <br /> -ISO S. -%ALA O&YS'To <br /> IL TANK DESCRIPTION <br /> TANK ID 0 Z. 43; TANK MANUFACTURER 433 TA CONFIGURATION: THIS TANK IS 33+ <br /> [ A STAND-ALONE TANK <br /> TA O 132- DW flsNS IT <br /> Q2. O INA aclAom EmgniDn UeVw <br /> DATE UST SYSTEM INSTALLED .435 TANK CAPACITY IN GALLONS 4x NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> d 1-1 g It 000 <br /> 'L III.TANK USE AND CONTENTS <br /> TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ie.AVIATION FUELING 411 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE([.dudes Usee oil) ❑ 5.EMERGENCY GENERATOR FUEL(11sc 4252RI.-'(c)l <br /> ❑ 6.OTHJM GhNER TOR FUEL ❑ 95,UNKNOWN ❑ 99.0THER(Spcci C3•): 430a <br /> CONTENTS PETROLEUM: Ia.R(GULARUNLEADED ❑ toAIIDGRADEUNLEADED ., lb.PREMIUM UNLEADED 4411 <br /> 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETRPLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 14111 <br /> NON-PETROLEUM:❑ 7.USED OIL, ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPEOFTANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN tat <br /> PRIMARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ecir). 14.11 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED +ss <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S cifv): 4153 <br /> OVERFILL PREVENTION I.AUDIBLE$VISUAL ALARMS 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> 4 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑I.SINGLE-WALLET 2.DOUBLE-WALLED ❑99.OTHER <br /> SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR 61200ai(3) 1cr <br /> PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 16) <br /> ❑ 9D.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x <br /> SECONDARY CONTAI NNIENT ❑ L STEEL DE 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 14.RIGID PLASTIC arab <br /> ❑ 9D.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ): *'ac <br /> PIPINGFFURBINE CONTAINMENT SUMPTYPE ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 1(411 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL Of 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Spccity) 1t.Is� <br /> .(rae i <br /> VENTSECONDARY CONTAINMENT ❑ L STEEL4.FIBERGLASS 10.RIGID PLASTIC [190.;LONE 99.OTHER(Specify) fru' <br /> _ •• xan <br /> VR PRIMARY CONTAINMENT J1 4.FIBERGLASS LI I0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) rias <br /> ✓ N.Ici <br /> VR SECONDARY CONTAINMENT ❑ LSTEEL 1& 4.FIBERGLASS I0.RIGIDPLAs5nc 90.NONE C3 99.OTHER(Specify) lrah <br /> 1r.Ih1 <br /> VENT PIPINGTRANSITIONSUNIPTYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 1r ti. <br /> RISER PRIMARY CONTAINMENT rA 4.FIBERGLASS Ll 10.RIGID PLASTIC ❑ 90-NONE 99 OTHER(Specify) <br /> .LAiI <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL 06.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4"1 <br /> 4rakl <br /> FILL CONSPONENTS INS rALLED jK I.SPILL BUCKEI Xr 3.STRIKER PLATE/BOTTOM PROTECTOR •I.CONTAINMENTSUNIP 4513.e <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONS]RUCTION TYPE 1,SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.YO DISPENSERS ❑ 00.`ONE 'u')2 <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL J&4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 169t- <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION _ SACRIFICIALANODF(S) ❑ 4.AMPRESSEDCURRENT ❑ 6.ISOLATION 448 <br /> IX" APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thnt thiS,UST stem is compatible with the hazardous substance stored and tllal the information provided herein e,true,accurate. <br /> and in full com liancewith Itgal re uir+entents. <br /> APPLICANT SIGNATURE DATE I aa, <br /> APPLICANT NAME(print) 471. APPLICANT TITLE 472. <br /> UPCF UST-B-112 <br /> 9'd IOZZ-99t-60Z I4151M eOUGJMBl d8b:90 60 2 Ue <br />