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05/20/2009 13:53 2094E .381EMIIRONMENTAL1LTH PAGE 03/04 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPER•ATWGPERMIT APPLICATION-TANXI ORMATION Onefom c,um YE OP ACTION (Check one item only, For a UST permanent closure ortemoval,complaw only this section and Sections 1,II,II;N,and DC below) Am 1.NSW OP.ARY 3.RENEWAL PERMIT e•TpMPOR MA UST CLOSURE i,UST PERMANENT CLOSURE Sil'E ❑ S.CHANGE OF INFORMATION DATE UST PERMANENTLY CLOSED: ,C sea 8.UST REM V A'I�GI DATE 67(ISTINO UST DISCOVERED: FACILfTY ID 0(All Use A]IyJ L 1FACILITI(INF 1RMATION BUSINESS NAME(Same u PACII,RY NAMG or DHA-De1o8 Husineu Aa} BUSIN S / ` L/ a CITY S 70(-"e e TANK:IDRI M TANK DESCRIPTION 'L u1 TAN FACTURER LAI T CONFIOVMrTON:THIS TANK IS Ill �Q � STANO,AOpNE TALAR AT USTS "I Q ❑2. HwA COMPARTMSNTep I/PDf, I�IjST ED �>+ T (,`,1o•r• w LON NUMBER COb��°Nc .n 1& MPARN THE UNIT .n tANR usE Moroi velRCLE IVELIxG I"'ll TAMC USE A D CONTENTS ❑3.CHBMICAL PRODUCT STORAGE 16.MAAR7APUELIN0 O Iv.AVIATION FUELMO IJP ❑ 40THEROENERATOR N6L US WASTE Ioelul 0 5.EMERGENCY GENERATOR NEL CONTENTS PHTROL6t1M: ❑9f.UNkHO 1199.07r{6R( cci ; f'�It9si5(.)I ❑ Ii REGULAR UNLEADED Q Ic.MIDORADEUNLEADED Ur. ❑ S.DIESSI. Q.3.]HPFUEL Q Ib.PREMIUM UNLEADED 110 ❑ LPIITROLBVM Bt[ND NEL Q 9.07H6R P6TROLBUM LI 5'AVIATrol NON•PETROLEUM:Q 7.USED OIL p Io.ETHANOL S 114 I I.OT)tpt NON•IHTROIEUM L /lob r"ll OP TANK IV' TANK CON$TRUCTION PRIMMYCONTANMENT SINGLE WALL P. IV. WALL 93.UNKNOWN .STEEL 3.FIBERGLASS ❑4.INTERNnt➢LADDRR 4p SRC'ONDARY CVMANMENT 7.STEEL♦INTRNAT.LTMNG 93.UNKNOWN IN ❑ 1.STER, ].FIEEROLA9s 9P.OTHER , ul. .NONE 95.UNKNOWN QS•MERIORMEMBIANELINEit 7.IACKETED OVERPILLP EVFNrtON 9s,OTHER 3 , 113 L^VW*41l VISUAL ALARMS 1.nALLPLOAT U3. 1.TANK MEETS REQNREMPMS PORE)AVAMONvil OVERFII.0 PRVMM FMNaIISHUTAPP VALVE I ' V, PRODUCT/WASTE PIPING CONSTItU ANN II VOMENT RN 'V ff PUG CONSr)tUCNON L6wGLE-WACLED xDOUeCTrWALLBO 99.OTHER PRIMASYSTEITYPB I.PReUtUt R.ORAVfTY 110 PRIMARY COMAWMSN7 Y 1•STEFy NVSNTI NAL SUCTION .1,SAF65UCTtpN Sf cCR m .J IJa Of/ Q 9p.NONE 1 4.FIBEAGLASS s,FLEXIBLE ❑ 10,RIGID PLASI7C SECONDARY CONYANMS)i Q 93.UNKNOWN E3 OTHER cl 101 1. EL 4.FIBERGLA93 6FLEXIBLE /Ala PIPN(:/TVR8INE CDMMNMENi NONE 093.UNKNOWN Q99.OTHER cd 10 t .RIGIA PLASTIC lab SUMP TYPE 1.SwGLfi WAµ 1.DOUBLE WIRIc VI,VENT,VAPOR RECOVERY LA$5 90.NONE vEM PR1MnxY CGNTnrNMeriT (VR)'AMSER,/FILL E PIPING CONSTRUC'T'ION 1 STEIIL t.P188AGID.RICID PLASTIC VEO.NONII 99.OTHER(S)cc"w 161e. M B6CONOAAY CONTNNM6N7 I.STEEL 4.FIBERULAS9 VR PRIMARY COMAINM4M IO.AIGIDPLASTIC .NONE pg,OTI�R(gpc4fY) IlNccit I.STEET, 1,FIHfiRO1 10.RIGID PLASTIC NE 99.OTHER Tun VR SECONDARYCOMANMp(T I.STEEL J I.FIBER (SPeeifY) 4MA PlNGLA5.9 I0.R1wD PLASTIC .NONE 9y,OINER I" VENTPIUM TRANSITIONSULry TYPE I.SNOLEWALL (Specify) 4Mb RISER PALMARY CYIMANMINT S .2DOUH1.8 WALL ,PIONS Illnl L SILFy t.FIHfiROLASS MM TE .. .A107O PLA$ leli A1SER 56CONDARY COMANEN 59,O1NeR(Speeify) 1 . I.SE L I.FIBERGLASS 10.RIGID PLASTIC 1 FILL COMPONEMSIN3TALL6D •NONfi 99.OT)I6R(Specify) IMk I.SPIµBVCK67 3.37R]XEIt PLATF/BOTTOM PA07ECTOR 4.CONTNNMENTSUMP I 1 VII.UNDER'DISPENSER CONTAINm l 1hIEN 1 ..e CONSTRUCTION TYPE ❑ 1.$NOLE WAµ CONSTRUC110N MATRRIAL 1.6TEP1, ❑ 1.FIBERGLASS Q 4 Dpt1HLS WAµ S.NO OISPENEERS 0 90,NONE u9. `i 10.RIGIDPLASTIC' ❑ 99.01HER b eel VIII. C0IIROSIOIVFROTECiTION . 1L6c STEPI•COI+PONENT PROTBC710N 112.SACRD'[CTAL ANOD � Q 4.IMPRE83ED CURRENT Q e.ISOLATION .sec IX. APPLICANT'SIGNATURE CERTIFICATION:1 cortlry that 04 UST system Is tempatlbPo With the 1, 4,. anbPaneo aterod and thPt the IntalwaUoo provMaa herRla H true,aaartfe, aURE rallmm IlnRcew1i Ir dremona. APPLICANT SIGNATURE DATE APPLICANT NAME(print) - i UFCF UST-3-117 Zf/ Rev.(12400'!)