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05/20/2009 13:53 2094 1138 ENVIRONMENTAL -ALTH PAGE 03/04 <br /> l .1l . ti0 1/ ( lIic <br /> -1 to Qd �� "l Ll 1�1_ 1,7 <br /> UNIFIED PROGRAM CONSOI IDAT RM <br /> UNDERGROUND STORAGE TANK <br /> OP)EXtATINGPERMIT REPLICATION-TANK INFORMATION one forter s <br /> TYPE OP ACTION (Cheek one item only, Fora UST permanent CI05I"ornmoval,tonplete only this.'action and Sceliom 1,B,III,IV,and IX below) 43n <br /> I.NEW PERMIT 3.RENEWAL,PERMIT <br /> Lj 6.TEMPORARY UST CLOSURE 7.U 11 s,CHANGE OF INFORMATION <br /> ST PERMANENT CLOSURE ON SITE B.UST REMOVAL <br /> DATE VST PERMANENTLY CLOSED: .C{✓t.ItJ 13 DATA EXISTING UST DISCOVERED: VV!Y_jV0WA) 06 <br /> FACILITY ID ri(Agmry Uae Only) 1. FACILITYINFORMATION <br /> BUSINESS NAME(Sone u FACILITY NAME or DBA-DoInA Amimu As) <br /> AUSINB. 5 (/ <br /> CITY 1�/ S�G�T�I <br /> IL TANK DESCRIPTION <br /> TANK ID 3 01 TANK:MAPIUPAC7�1 RaR, 'A' T cowman nom THIS TANK is 434 <br /> -N- T Nc"LONBTAW <br /> 0 <br /> 2.0 <br /> NB IN ARTMHNTWUNII'. <br /> DATEU. Iyl$TAJ„I,� w TAN poarrry*v rer. tl0O1 t0' �mNe <br /> ONS � NUMBER OP COMP 7 NU4 THE UNIT ur <br /> ri- <br /> ILTANTCUSEAN CONTENTS <br /> TANK USE MOTOR VEHICLE FUELING ❑ APUBLINO <br /> Ll3XIIHMICALPRODUCT STORAGE ❑ {,yA,E AVIATIONFUELNO 439 <br /> 0 b.OTHERCENERATOR FUEL ❑ 95.UNKNOWN 9.6MSRGENCY GENERATOR FUEL pT9ct}R1I3(c)] <br /> CONTENTS pETROL6UM: ❑ IL REGULARUNLEADED ❑ 99.077 1 cel ): q9s <br /> 0 3.DIESEL ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ f.lBr FUEL ❑ 6.AVIATION OAS <br /> Cl f.PBTROLEUMBLBNDFUSL ❑9,OTr(fiRPETROLEUM �] -y <br /> NON-PETROL IRIM:❑ 7.USED OIL ❑ IO.EPHANOL 41Ca <br /> I I.OI]{FIe NON-PETROLEUM ' <br /> 4406 <br /> IV.TANK CO (STRUCTION <br /> TYPE OF TALAR SINGLE WALL ZDOUBLBWALL 9f.UNKNOWN <br /> PRIMARY CONTAINMENt ,STEEL ❑ ),FIBERGLASS Ida <br /> 7.STE84+iNTD.1eNA1,4R1RT0 ❑--11- NAL BLADDRR aq <br /> SECONDARY CONTAINMENT u LSIy 095.VNINOWN 99.OTHSR 3 cif 4444 <br /> 3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER 7.1A TED ul <br /> .NONE ❑ 95.UNRNOWN 99.OTHER 9 f <br /> OVERFILL PREVENTION I,AUDIBCBA VISUAL ALAR MS s.BnILFLOAT ul. <br /> ❑{.TANK MEETS RB.QUIREMWTf$POREXEMPTION FROM OVERFILL PRBVPNI7ON EQUIDMINV LVfi <br /> V. PRODUCT/WASTE PIPING CONSTRICTION <br /> PIPINGCONSTRUCI7DN I.SINGLE•wACLED ZDOUBCEWALLBO ❑99.OTHER <br /> SY$TI!biTriB I.PRESSURE 2.GRAVITY NVET1T10NAL SUCTION I.SAF6 SUCTION rS ttR12636(.x3)? ua <br /> PRIMARY CONTAINMENT/ L STEEL ❑ 4.FBERGLASS ❑ 8.FLEXIBLE <br /> ✓f/ ❑ 90.NONE ❑ 95,UNKNOWN 0 99.OTBER el(y: ❑ tO.RIGID PLASTIC fat <br /> SECONDARY CONTAINMENT LSTEEL {.FIBERGLASS s.FLEXIBLE tu. <br /> NONE 0 95.UNKNOWN 10.RIGID PLASTIC SMb <br /> PIPNO?URBNE CVNTMWW 6TIMP TYPL• 0 99.OTHSR 3 CCI *I <br /> LSINGLE WALL 2.DOUBLE WALL 90.NONE ar�d <br /> VL VENT,VAPOR RECO VERY(VR)AND RTSER,/FILL PIPE PIPING CONS'T'RUCTION <br /> VENT PRIMARY CONTAINMENT 1.STEBL IPIRBRGLASS 10.RIGIDPLASTIC O.NONH 99.0'1'RER($pON 164 <br /> VENT S6CONOAAY CONSAINMENT i.STEEL {,FIBEAOLA99 IORlGID PLASTIC .NONE 99.OTHER(SpeGfy) aaeall <br /> VR PRIMARY tOMA1NMfiM ❑ I.STEEL 1,FIBERGLASS ❑ 10,RIGID PLASTIC 141n <br /> VRSECONDARYCONTAINMENT NONE 99,OTHER(SPeeityI 4M2 <br /> 1.STEEL 1.FIBERGLASS 10.MOLD PLASTIC I. I <br /> .NONE 99.OTI(6R(3peeHy) 4916 <br /> VENT p7ININRY ONTION ENT TYPE NONE <br /> 7DOUBLE WALL '"hi <br /> RISER PRIMARY COMANMENT T.STEEL I.FIHEROLASS 'NONE IECL <br /> IO.RIOIOPI:ASTIC NONE 99.OYH6A(Spuih) tMl <br /> AfSER SECIXJDARY CONTAINMENT 1.STEEL 1,FIBERGLASS 10.RIOIDPWSDC ,MONS a I <br /> 99. ENTS(SpaNfY1 161k <br /> PILL COMPONENTS INSTALLED 1.SPILL BUCKET 3-STRIKER PLATTYBOTTOM PROTECTOR {.CONTAINMENTS451vc <br /> VII-UNDER DISPENSER CONTAINMENT(UDC <br /> CONSTRUCTION TYPE 0 L SINGLE WALL 0 3.DOUBLE WAµ <br /> SER <br /> CONSTRUCTION MATP,R(AL I.STP.EI, ❑ a,FIBERGLASS 10.RIGID DLA57IC ❑ 99N07NpR S al S ❑90.NONE arm <br /> .cabs <br /> VIII• COIRROSION PROTECTION <br /> STEEL COMPONENT PAOTHCDON ❑ }.,SACAIF[CIAL ANODE( O TIP PR63SED CURRENT <br /> 0 6.140LADON au. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I cerOry that thb UST ariteIII:b eompntldlo wllh the baalu'doua apbatRn<e pored and , <br /> her, <br /> fh�t the hltarmatlen rwlherein is h,e, ecanfq <br /> nndln Nllm linncewith Air tlremoate. p <br /> APPLICANT SIONATUREE DATE <br /> APPLICANT NAME(prim) 47I. <br /> iC TTj],E 172 <br /> UPCF UST-B-In 7 <br /> Rev.(Inion <br />