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UNIFIED PROGRAM CONSOLIDATED FORM Y 1b 10 UNDERGROUND STORAGE TANK � ' tzul'.. OPERATING pERbUT APPLICATION-TANK INFORMATION(pac raa per tap TM OF AC770N (Chsdf bnc k m aniy. For=USTrImmeav elo6Tltn or rawW,tmlq)Wc only the Wlion aid Seaias 1.11,111,TV,wW YX bdow) a10 i.New PERMrr ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION O 6-TEMPORARY UST CLOSURE a 7.USI PERMANENT'CLOSURE ON SITE 8,UST REMOVAL 4>m DATE UST PERMANENTLY CLOSER °' I DATE EXISTING UST DISCOVERED L FACILITY INFORMATION 1 FACILITY ID i(.geed Um Only) Li eL - - BUSINESS NAME(St as FACILITY NAME a DBA-Doing Bazmm A) BUSHIM;SITE ADDRESS1e} CYIY Moe 1789 W. W II.TANK DFSCRIPITON TANK ID/ 5 aITA MAMANUFACTURER 4Ji T��nyyyyyNK CONFIOt/1RwiiONTiig TANK IS 4'i4 I u �I. STAND-ALONETANK I rv^ S �rUS ) 2.ONEONE INACQNPAR'I MEM7:O L�1R. c6nglve brie f«oeAe o@emi DATE UST SYSIE'M INSTALLED 'ISz TANK CAPACITY IN GALLONS °'6 NUMBER OF COMPARTMENTS IN THE UNIT TANK USE AND CONTENTS TANK USE XI&MOIM VEBCIE R1F.'.IINU Q i6.MARNA FUWIW ❑ Ic.AYLATLON FIMANG ❑ 3.CHEMICAL PRODUCT STORAGE O 4,UA7ARDOUS WAS F0.1. ckM N6 ❑ 5.GMMGENCY GENERATOR FUFJ jkLSC*SN's )1 Oma ❑ 6.OTHER GENERATOR FUF.1- [195.UNKNOWN ❑ 99.OTHER (Specify). CONTENTS PEMOIFI/M: Q Iz.RDGIILAR UNLEADED Q Ic.MIDGRADE UNLFADrD IK Ih.PREMIUM UNLEADED 4°e Q 1.DIV!SFL ❑ 5.JET FUEL. ❑ 6.AVIATION GAS O &PETROLEUM BLIND HES. Q 9.0'IiGR PM- OL.F.UM NON.PETROLEUM:0 7.USEDO11. ❑ 10.hit!ANOI. de0b Q 11.MIE RNON-PETROLP-UM IV. TANK CONSTRUCTION 7YPEOFTANK ❑ I.SINGLE WAIL 2.DOUBLE WAU. 0 95,(MKNOwN 44s I PRIMARY CONTAINMENT D&I.STEEL LJ 3.FRMGIASS 06.INF-ANAs,RIADDFR 444 D 7.sTtF1.,IxTERxAL uwNc 95.uxKNOWN O 99.DTNIR SECONDARY CONTAINMET 1- ❑ I.S'(F71. ❑J.rdBFRG1 a cc 4.tJfiTRTOR MFAABRANE LINER 7-JACKETED acs 90.NONE Q 95.UNKNOWN 99.OTFLFAI I: 4afe OVERFILL PREVENTION ).AUDR+1 F&VISUAL ALARMS 2.EIAU,FLOAT O 3.FILL TUBE bluff FT VALVE 40.ER ❑ 4.TANK MEETS REQUIREMCN7'S FUR�' FMPTLON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PtPBG COT6fRUCtgN ❑I SINGLE-WAueD IW2.DOUB[bwnt t cn ❑99.OTHER dss 5YS-1 �.pEX Ig 0 i.GRAVITY S.CO ,.1 ZONAL SUCTION ❑ a.SAFE SL'C7FON 3CQ 7 � PRIMARY CONTAINMENT U I.STEEL Q 4.FIBERGLASS S.FLEXfBLE ❑ 10.iRLG1D PLASTIC aha. ❑ 90,NONE ❑ 95.UNKNOWN C] 99.OTHER( ): SECONDARY CONTAINMENT ❑ 1.Sil.Fl O d. Ute` lie 8.FLE7cIB1.F. O 10.RIGID PLASTIC 90.NONE ❑ 95.UNKNOWN ❑ 99.07'H£R(Spcci'): rypRN(JIRJRBnIECUNTAIMENr SUMP TYPE 1.35lO WALL (32.DOUBLEWALL. 090.NONE VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL.PIPE PIPING CONSTRUCTION .aw VENT PRIMARY CONTAINMENT u I.$TT'-.r'-L 4.FIMRGLASS 10.RIGID PASTTC Lj W.NONE U99.O'IHEX(Specify) ebaet VENTSIX)ONDARY COMAI MrN`T ❑ 1.SELF-L 4.FlBERGUSS Q i0.RIGID PLnS7'IC 90NONE ❑ 99.OTHER(Spa+fyi VR PRIMARY i5M A)NMENT I.STElSL 4.FlBERGIA$5 10.RIGID PLASTIC 090.W)NR 99,OTHER(Spey) 4fti VR SECONDARY CONTANWEIrT LSIF.- 4.P19ER45LASS 10.RIGIDPL.ASITC K90.NDNr, U 99.OTHER(SpecYy) 464, *41 VENT PPDfcTRnxsnTDxsump"rYPE 0 I.SINGUt WAIL a.DOUBLE-WAIL IFL 90.NONE as4 RMER PRIMARY CONTADOOENT 1.STEEL U a.PBFROLASS Q 10.RIGID PLASTIC ❑ 90 NONE U 99.OME((SO'Ay) , Rigie4FGONDARY COFTfA1NMENT ❑ STCFI. *4.f1BFRG1A55 ❑ 10.RIGID PLASTIC 90"NONE 99.OTIim(spew 4�t FILL COMPONENTS THSTAILED SPILL BUCKET .Sl-RIK3s'R PV.TEISOTfOM eWtECTOR Q L CONTAINMENT SUMP 4PIs4 VII.UNDER DISPENSER CONTAINMENT(UDC) COTLVTRucnON TYPE !.SBKiT.E WALL ❑ 2 DOUBTS•WALL ❑ 3.NO DISPENSERS 0 OIL NONE d69e CDHSSRUCITOH MATERIAL ❑ 1.SiE1S1- 4.ETPIERGIASS l0.RIGDPIA57iC ❑ 99.OTF2R ) 4Nhc VIII. CORROSION PROTECTION ITER tXl►POrfkT4"f PROTECTION Q 2.$ACRIFKuL ANODT(S) ❑ a.IMPRET$BD CURRENT Q 6.!SOLATION 4fY IX. APPLICANT SIGNATURE CIERTIPCAT M: I mtif>tgat das UST 11n is cp>raI RA-.rith the imxprdeetz swbbeaxc coral CIM Ater Ree iarprnlW Ion prevkled he Wm Is 1314 no 6% CIM in ran vich Ito m rq APPUCANT SIGNATURE DATE .�/71 �L J an a71' APN PLICAT=TrFL / r AMXANTNAM ) ��✓gr•1(7 C-� 7 R9v.(12rIgl7) UPCF USP-B-m 810/000 d V6309 aoeld�a>IIeN A.1}unoo SZZZLV660ZL 61 61 OLOZ/90/UO