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PROGRAM CONSOLIDATED FOAW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMA O Q ;c form per usn TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111.Il:and IX below) 430. ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 4M. I FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 1 B INESS NAME(Same as Facility Name or DBA-Doing Business As) 3. _ RI BI JSINVSS ST ADDRESS 103• CITY 104. H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTU R t 433• 7 gNK CONFIGURATION:THIS TANK IS - 434. r` ,�/1.A STAND-ALONE TANK C pkte one page for ewh '�� FJ/�.�.�� 15 2.ONE INA COMPARTMENTED UNIT a ;went in the unit DATE UST 7STEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE NIT 437. ( ,:?- Coo III. TANK USE AND CONTENTS TANK USE--49 9 la.MOTOR VEHICLE FUELING E3Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439• ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Incbx s Used Oil) ❑ 5.EMERGENCY GENERATOR FU tmc§2s-1.5(c)1 ❑ 6.0THER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. CONTENTS PETROLEUM: --V la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS [38.PETROLEUM BLEND FUEL [39.OTHER PETROLEUM(Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify). 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT 1M T.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ ".OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ i.STEEL --®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4as. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMIN17S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ---421.PRESSURE ❑ 2.GRAVITY E33.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR I S6(ax3)1 458. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99-OTHER(Specify 464x. SECONDARY CONTAINMENT ❑ I.STEEL ' --® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE T.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUE ;TION VENT PRIMARY CONTAINMENT ❑ 1.STEEL-4 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 1399.OTHER(Specify): ' 46440. VENT SECONDARY CONTAINMENT [11.STEEL -El 4.FIBERGLASS El10.RIGIDPLASTIC 1390.NONE ❑ 99.OTHER(Specify): a4Mfj; VR PRIMARY CONTAINMENT ❑ 1.STEEL--f9 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): S; VR SECONDARY CONTAINMENT ❑ 1.STEEL--®4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 46461; 464 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL [32.DOUBLE WALL ❑ 90.NONE '' RISER PRIMARY CONTAINMENT ---'b I.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464"1. RISER SECONDARY CONTAINMENT ❑ 1.STEEL---�M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46ak1. FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRUM PLATE TTOM PROTECTOR 4.CONTAINMENT SU. 451a<. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.N ''IE __. 469a CONSTRUCTION MATERIAL -® 1.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC ❑ 99.OTHER(Specify) 46% VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION E32.SACRIFICIAL ANODE(S) 4.A CURRENT 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored acid that the information ProvW , bereila is true, accurate,and oo with lend requirementL 470. APPLICANT SIGNATURE DATE ] APPLICANT NAME(print) 471' APPLICANT TITLE f'_ �. e 4 72.} UPCF UST-B Rev.(1=007)-1/2 www.anidocsorg INA � '