BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

Ask az IFIED PROGRAM CONSOLIDATED FO q(�(( 3 ly1L UNDERGROUNDSTORAGETANKf"� OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete oNy this section and Sections I,H,IH,IV,and IX below) a30 ❑ 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: 43W DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bus As) 3 Za GiQUU� BUSINESS SITE ADDRESS p @0 3 c 4%0_., l04 D U.TANK DESCRIPTION TANK RJ# „ ( S'K 050 87.4 432 TANKI'31 on v IrMANUFACTU/RE-R 433 [NKCONFIGURATION: THIS A STAND-ALONE TANK TANK IS 4N 7 1 � (f f( J 1 R2.ONE w A Cotr�AR'1'MENIED IINI'f. l \\\ --- de ue f«mdi cam wv�mtin ae�t. DATE UST SYSTEM INSTALLED 035 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPO ENTS IN THE UNIT 437 ^quo III.TANK USE AND CONTENTS TANK USE la MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6a1Wm Us ail) ❑ 5.EMERGENCY GENERATOR FUEL RISC M21313(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4Me CONTENTS PETROLEUM: ❑ Ia REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED 1b.PREMIUM UNLEADED 400 ❑ 3.DIESEL ❑ 5, FT FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 410° NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 19 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 112 7.STEEL+INTERNAL LINING Cl 95.UNKNOWN ❑ 99.OTIHER (Specify): 444e SECONDARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE 95.UNKNOWN 099=R . S 4454 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FL3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR E"AFTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 0 2.551 LE-WALLED ❑99.OTHER 450 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[M CCR JM6(BX3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 19 4.FIBERGLASS ❑ S.FLEM13LE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS ): 464° SECONDARY CONTAINMENT ❑ L STEEL d 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(So.*): 4Me PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)ANDER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4Ne 469e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464fl VR PRIMARY CONTAINMENT ❑ L STEEL JR 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) e VR SECONDARY CONTAINMENT ❑ 1.STEEL K 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 469h1 VENT PIPING TRANSITION SOW TYPE ❑ INAGLE WALL [12.DOUBLE WALL [190.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.DINER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 11 90.NONE ❑ 99.OTHER(Specify) 4641 464k1 FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET D 3.STRIKER PLATF/BOTI'OM PROTECTOR ❑ 4.CONTAINMENT SUMP 0516-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [I 90.NONE 469e CONSTRUCTION MATERIAL IN 1.STEEL ❑ 4.FIBERGLASS ❑ 10.]UGID PLASTIC ❑ 99.OTHERS ) 4696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE =, Y ,Fl CERTIFICATION: I cerlify that this UST system is compatible with the hazardous substance stored and that the informs[ n pmi4ded hereliLite, and in fall compliance with uiremeata. APPLICANT SIGNATURE DATE 3- /4-,A 1 .t LL APPLICANT NAME(print) 171. APPLICANT TITLEAR 4 2012 "ve 9614d .a.;i,;Rr1N�VIE�s�r•.1. UPCF UST-B-1/2 -