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-,(TNIFIED PROGRAM CONSOLIDATED FOS! V A <br /> UNDERGROUND STORAGE TANK <br /> OPERATING MMT ApPIdCATION-TANK INFORMATION(Goa farm UST) 4)o <br /> TYPE OF ACZON (Check ane igen only. For an Ur r0nuBw Ck)SIRE of ronod,compile only this sEd10t and Strums I.Il,iii,IV,aed IX bcbw) <br /> ( rggr pE'RMTT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INPORMATION <br /> [] 6.TEMPORARY IAT CLOSURE T L'ST PERMANENTCLOSURE ON SITE S.UST REMOVAL A <br /> EFAACRJTY <br /> UST PERMANENTLY CLOSEST. am. DATE EXISTING UST DISCOVERED: <br /> L FACILM INFORMATION <br /> 'D a(A0r c Ux ONlY) I NESSNAME(Sw =FACILrrYNAMEMDBA-Doing�"-AS) <br /> lNfAiITYtAmSITEADDREss St0 rJ cT u . VkD.TANK DkSCR1-F---IDI r2 • TANK MANUFACTURER 'r' �TpANK Cll1dP!G--moN: T MTANK iS <br /> �^ i Itp I.A STANaAIONE YANK <br /> -r(-V`S Lo y 2.ONE.IN A COMPARI'MF.NYY M`fT. <br /> 1\ v - Y i•/ <br /> -r(-US f aac 0.rm saeea ar <br /> DATE UST SYSTEM INSTALLED 'lts TANK CAPACITY IN GALLONS ''" NUMBER OF COMPARTMENTS IN'ME UNIT <br /> O <br /> UL TANK USL AND CONTENTS <br /> TANK USE Wis.MOTOR VEMCLE PGEUNO ❑ Ib.MARINA FULLING ❑ ie.AVIA11ON FUELING <br /> C) 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZAR0OUSWA9V-(I- f I-e Nn Q S.ES/FRGFNCY GE]VERAIDR FUECfr4C453fISKH . <br /> 95.UNKNOWN U 99.OTHER(Swit9Y- <br /> i] QOTlmt GENERATOR ItiEI OWN❑ 449 <br /> ODNIENIS PETR(ri.EAi: i..REGURAR U?P.EADED i<.MLDGRAD6 UNLTAOEJ) 0 PREMIUM IJNLEIDFD <br /> 0 <br /> Q 3-DIESEL 5-JET ELF.I. ❑ 6.6.AVIATION GAS ab ! <br /> Q &PEf'ROLmLR4 BLEND FUT1 [3 9O HER PCfR01.1M (semf0' <br /> NC*p ROLEUM:El i.USED 011. 0 10.ETHANOL .rtc <br /> ❑ 11.OTHER NON-PETKOLiUM if" <br /> iV. TANK CONMUCTION «. <br /> tYR OPTANK I.SINGIEWALL 2.DOl/EI;WAU, y53NTTN�Wx1.ADDER <br /> PR04MY CONTAINMENT $I.ST ❑ 3.FlBFAGLISS «.. <br /> 1 STII.+INTERNAL LtNINO 95-UNKNOWN 0 99.OTHER ].JACKETED <br /> GARY CONfATN?IEN1' ❑ 1.STEEL p 3.FIBFJtGLASS ❑ 6.EXIP_RtOR MEMBRANE.IaNE3t�. .� <br /> ,r] 9o.NONE ❑ 95.UNKNOWN 99.OTHER( )' �// 12w <br /> DVEtET7L iPREYPNDON �,1.AIJDiBti&V ISI:nL ALARMS l DOLL Fl.OAT 3.PILL TUBE SH IT-0 J-VALVE <br /> Q 4 TANK MEETS REQUIRJ'l4ENTS i'OR EXEMPTION PROM OVERFIU.PREVENTION EQl:fPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION ---I' <br /> RVP91cCpIgIRULTY N 0 t.SINGLE-WA LED DWB WAUL'D 099 OTHER 4$2 <br /> yygrHe TYPE I.PRFSS()RE 2.GRnvITV p J.CONVEdTtONAL S[K'1TON ❑ a.SAFE SliCTlOPF 4'1CCE dw <br /> PRIMARYODNTAINMFNf ❑ 1.S7'FiL ❑ 4,FlBETtGL9S5 �.I.PLEXIB)2 ❑ I0.KKJiDMASTIC 4W 1 <br /> O 90.NONE D 95.uNROJOWN ❑ 99.OI ): .s.e <br /> SECONDARY CONTAINMENT' I.STGEf, til d.AHERGLA55 e.P-MIBLE p IQ RRGID P(AS'rtC 4ad. <br /> ❑ 90.NONE ❑ 95.UNKiIOWN ❑ 99.OTHER 'HY a544 <br /> TIPNCdDJtew CoT ARa[wr SUMP TYPE 1.SINGI.E WALL U 2.1.WALT, 90.NONE <br /> VL VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION .ea <br /> vVNTPRNAARY CONTAINMI?t.R s-T[P•.L a FlxERcuSs ❑ to.RIGID PLASTIC 90.NON- 99 oTNFR(SpeITS') i <br /> :o.RIG[O I IASl1C �cr 9D.NONE 99.OTHER,(Spa fy) <br /> VENT SECONDARY CONTAli iiia SRT`-- ..Fl9ERGl.',55 1! <br /> a,FIBBRGIA55 t0.RIGID <br /> Al <br /> ❑ 90.NONE 99.071TE1(SPaT� i61� <br /> YR PRAIARY CONTAI9NA i ❑ f.STEEL .6A <br /> VR SECONDARY CONTAINMENT <br /> I.SYFEL 4.FIBERGLnSS ID.ftlGID P[ASTIC m.NONE 99.O1Hgt(SpxYy) 4iNI <br /> 2.DOUBLE W AIL 90.NONE 46� <br /> VENT PIPING 7R.AlRSSO,y BUMP TYPE I.SING3J=WAIL ;O.RIGID PIAS'OC 90.NONr 99 onwR(Sp�TY) <br /> JIM PRIMARY CONTAtNMSN'1' �.suS' - © <.ERBFRG[ASS <br /> 10.RIGID PLASTIC 90.NONE p 99.OTSiEK(Wwfy) .et <br /> 'ISM SBCOd RY CONTA!NMP1.'T 0 i.STCEI. 4.TIBERMASS ❑ 4adk1 <br /> pn.L P DNMM INSTALLED I.SPILL ffiKKEY 3.3TR{KER P1ATF/BOTTOM PROTLq'NR 4.CONTniTBiBN-f SUMP <br /> eSls <br /> ViT.UNDM DffiPENSER CONTAINMENT(UDC) .eae <br /> C096TRi9CT[di TYPE E SINGLE WALL, O 2.--U WAu ❑ 3.NO D6PEraSPS ❑ 9D NOME <br /> CO#STRUCIWN MATERIAL i.STTSL Q 4,ROERGLASS !0 RiciO PiAsTtC ❑ 99.OTHER ) <br /> VIII CORROSION PROTECTION <br /> ..t <br /> SNX.L COMPONENT PROraciloON O 2 $.ACRIPICL, AmowPs) C) 4.iMPR!<¢m CURRENT 0 t.soLATION <br /> IR. AMICANT SIGNATURE <br /> Ct�i7'1F/CA770N: r tePNLY that bis UST s,Y#cs+is rsswpiHM<rith tl.e heardod+subuarec Aorod.nd chat the 1968rmehen PreNdbM bcdn k lw8 <br /> and in PA wKh resN/4115. d]0. <br /> RATE <br /> ! AFMCANTSIGNATURE <br /> a7r <br /> 'n. APPLiCANTTTTLE <br /> I Af'PucwNTnnME(pltm) (t,�� <br /> ^!I C� e <br /> _j <br /> Aa.'-y1T13M'T) <br /> IWCF UST-8-M <br /> CLO/SOS d b6ZOR BoeTd}@>jew RJ}unoo 6ZZZLP660Z1 6Lo61 ow/go/Po <br />