BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

c NWIED PROGRAM CONSOLIDATED FO (4-2 UNDERGROUND STORAGE TANKI OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST pefmanent closure or removal,complete only this section and Sections I,II,IE,IV,and IX below) d30 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE ❑ &UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID II(Agency Use Unh) - 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business r 3 f' IN BUSINESS SITE ADDRESSC�.✓°k!�- 0 IL TANK DESCRIPTION TANK IDX 02 TANK MANUFACTURER °33 TANK CONFIGURATION: Tw$TANK[S 4Mrsy,�m�� /1� [ C]LA Com deSTAND-ALONE TANK 3q W� {4� R2.ONE RI A COMPARTMENTED UNIT. �' VV me foreadi ,,a mtinlhewie DATE UST SYSTEM INSTALLED °35 TANK CAPACITY IN GALLONS °36 NUMBER OF COMPARTjvIEN rs IN THE UNIT 437 (a7 U (� III.TANK USE AND CONTENTS TANK US MOTOR VEHICLE FUELING ❑ Ib.MARINA FUEDNO ❑ Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCF STORAGE ❑ 4.HAZARDOUS WASTE(mdu UW Oil ❑ 5.EMERGENCY GENERATOR FUEL IRSC 1u281 X01 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER S 'fy): 43% CONTENTS PETROLEUM: ❑ lm REGULARUNLEADED ❑ Ic.mux RADE UNLEADED ❑ Ib.PREMIUM UNLEADED °40 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 449e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 4406 ❑ IL OTHER NON-PETROLTRIM S IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL WN 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 'IN .STEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.O HER (Specify): °°4e SECONDARY CONTAINMENT 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 90.NONE ❑ 95.UNKNOWN [199.OTHER S ' 445e OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS U 2.BALL FLOAT it 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CON5714UCTION ❑1.SINGLE-WALL® IK2.DOABLE-WALLED [199.OTHER 468 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(W)l 458 PRIMARY CONTAINMENT ❑ 1.STEEL IN 4.FIBERGLASS U S.FLEXIBLE ❑ 10.RIGID PLASTIC °64 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTIIIX(Sfy): SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE �.I.SINGLE WALL ❑ 2.DOUBLE WALL [1 90.NONE °69d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.mull PLASTIC 90.NONE 99.OI7I1R(Specify) 464e1 VENT SECONDARY CONTAINMENT ❑ Ls L 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spedfy) 464E 'IN11 VR PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify) IN' 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPmfy) 46°h u hl VENT PIPING TRANSITION SOMI TYPE 1.SINGLE WALL n2.DOUBLE WALL ❑ 90.NO 464r. RISER PRIMARY CONTAINMENT L STEEL U 4.FIBERGLASS Lj 10.RIGID PLASTIC U 90.NONE U W.U114ER(SPeafy) �) 4641 RISER SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASSr310.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k1 FILL COMPONENTS INSTALLMt. CKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT'SUMPNDER DISPENSER CONTAINMENT(UDC)CONSTRUCTION TYPE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONECONSTRUCTION MATERIAL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.0"1'FIBR($pd VIILCORROSION PROTECTION STEEL COMPONENT PROTECANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION - IX. APPLICANT SIGNATURE CER7IPICATTON: I ratify that this UST system is compatlbk with the hazardous smbstm ee stored and that the imfay� pypyided hereW Accurate, and in fuB compliance with 1 requireament& _ T- DATE / a, 1. 470. APPLICANT SIGNATURE , APPLICANT NAME(print) /) 2� I ,..n 471. APPLICANT TITLE 4� UPCF UST-B-1/2 rl w-ONNlErvI�^(�.