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l Cy UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) FDATEUST N (Check one item only. Fora ST closure or removal,complete only this section and Sections 1,11,111,IV,,and IX below) 430. MIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ARY UST CLOSURE 7.UST PERMANENT CLOSURE ONSITE ❑ 8.UST REMOVAL MANENTLY CLOSED: _ 430& DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) IF I NI -101-1 -1141 L 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. MNO S-TQEET kfJ_0 #MPM - K �S Etj- EP_PP_i sG LL BUSINESS SITE ADDRESS 1°3 CITY 104. 1100 S. MhIN ST�EE? MI�NrtcA C 9533 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Q 1 U M 1 NEkDo n V 1.A STAND-ALONE TANK Complete one page for each 1' U \A E t�t�E S. 2. ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING [3 lb.MARINA FUELING [3 le.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] _❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN 13,99.OTHER(Specify): 439x. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED Alb.PREMIUM UNLEADED 446-- 0 4o❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 44 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+ AL INING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify). 444a SECONDARY CONTAINMENT ❑ 1.STEEL )K3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445& OVERFILL PREVENTION1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT D 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION .❑��.-1�.SINGLE WALL 2.DOUBLE WALL ❑ 99,OTHER ____ __„_,_____ 460. SYSTEM TYPE �1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§263 e 3 458. PRIMARY CONTAINMENT �❑ 1.STEEL ")K4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464& SECONDARY CONTAINMENT ❑ 1.STEEL4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. 1390.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): _464c_ PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT [31.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [:] 99.OTHER(Specify): 41. ---- - VENT SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE [399.OTHER(Specify): 4(Af - _._. 464 VR PRIMARY CONTAINMENT ❑ 1.STEEL I[4.FIBERGLASSEl10.RIGID PLASTIC [190.NONE [3 99.OTHER(Specify): 464 9.111. ---. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTI�90.NONE [399_OTHER(Specify): 464 h. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL V-02.NONE 464` RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): -AL ............... RISER SECONDARY CONTAINMENT ❑ ].STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC19 90.NONE ❑ 99.OTHER(Specify): 464k1' FILL COMPONENTS INSTALLED - 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR - 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL _ ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE_ 469s CONSTRUCTION MATERIAL [31.STEEL 4.FIBERGLASS [110.RIGID PLASTIC [199.OTHER(Specify) 46q�. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full com fiance with legal requirements. APPLICANT SIGNATUREDATE 470 3 Zoo � APPLICANT NAME(print) V_0 L D,EE P C S�trn A 4"' APPLICANT TITLE LLC' 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org