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05/20/2009 13:53 2094115Th ENVIRONMENTAL Hr TH PAGE 03/04 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />I OPERATING PERMIT APPLICATION -TANK TNVORM ATTnTT <br />IW l 3. RENEWAL PERMIT S, <br />INC t�7 <br />e. Vel IKDMV VA <br />DATE UST PERMANENTLY CLOSED: CA/Li/ 1w! DATE EJUSTINO UST DISCOVERED: (/„/,rjLh•P„� <br />1. FACILITY INI,'ORMATION <br />FACILITY ID n (A(IRCP urr OnIyJ <br />BUSINESS NAME (Same s. FACILITY NAME er DBA•DoIeR Bu6ileu As) <br />c-iw <br />BU. 9 IN CITY <br />SrC,�Tp <br />ooA <br />, <br />IU <br />_ <br />M TANK DESCRIPTION <br />TANKqK IID# - - Y1t T'ANRMANUFACTURER AA1 T CONROURATION: THIS TANK IS <br />114 <br />STANthALONB TANK <br />❑2.MEm A CO ARTMENTDD UNn. <br />DATE UST SySTFM 1p1$I u+ <br />(/NK '•HTANKCAPACPALLONS NUMBEROPCOMVN TE UNIT <br />4.17 <br />TONICUSGAIVDCONTENTS <br />TANKUSEV5E MOTOR VEHICLE PUEUNG ❑ 16.MAWNA PIIECINC ❑ Ic AVIA770N FUELMO <br />0 J.CHBMICAL PRODUCT STORAGE <br />IN <br />E34. HAZARDOUS WASTE peel UWon) ❑ 5.EAVIATIOCYOENERATORNEL IIRCI7a11J(OI <br />O 6.OTHERGENERATOR FUEL ❑ 95. UNKNOWN <br />❑ S9 OTHER (Sell <br />CONTENTS FSTROLI ❑ 1 LAEOULARUNLEADED ❑ Ic. MIIMMDE UNLEADED ❑ Ib. OTHER <br />MM <br />DPD <br />❑ 7. DIESEL ❑ 7, JDT PUII. ❑ 6. AVIATION GAS <br />❑ f. P87ROLOND FUEL <br />BL ROLEUM <br />NON.PPrAOLEUM: 7. USRD OIL8UM ❑❑ IO. ETHANOLPETJ ; /ylig <br />%,'-(A <br />MO! <br />II.OTXp NON•PHTROLEII eel <br />N,' 1ANKCON$TRUCTION <br />4106 <br />TYPE OFTANK SINGLE WALL 3.DOUDI.H WALL 95. UNKNOWN <br />]PRIMARY El <br />.STEEL. J.FIBERGLASS 06,-1-11AL DLAODER <br />YJ <br />7. SMIll-INTERNAL LINING ElINKNOWN 95,I99.OTHER cif : <br />SECONDARY CONTAINMENT ❑ 1. STEEL TTJ, <br />I11 <br />MY <br />EtHBROL.A.SS U E EXTPJUOR MEMBRANE LINER 7, JACKETED <br />.NONE 95JIMNOWN I]99.OT"It 3INH <br />LP NGON 1, AUp1D48AVISVALA 1, 1' �. BALLPLOAT <br />WL <br />3. FILLTDBE SHUT-0PP VALVE I' d <br />El4.TANK MEETS REQUIREMENTS POR EKBMPTTON FROM OVERFILL PRSVINI'l EQVIDMENT <br />V. PRODUCT /WASTE PIPING CONSTRI)'CTION <br />P[PMGCONSIRUC170N I.SINCLE•wALLED 2DOUDLEWM1LLHD ❑99.OTHER <br />PRIMARTYPB I. PRESSURE 2 aRAVrrr NVENTI0NAL3 CTION /.9AFE SUCTION LCY.TI 65 . <br />PRIMARY COMAWMSN!/ LSTEEL L] 4. F(BERGLA99 ❑ B. FLEXIBLE <br />1aa <br />/IE 139D. NONfi C3 95. UNKNOWN L] 99.OTHER eclp•: IO. RIGID PLAS77C <br />SECONDARY CONTAINMENTCONTAINMENTL <br />01 <br />STEEL 4. FIBERGLASS 81" <br />, FLEXIBLE <br />NONE O 95. UNKNOWN11 10. RIGID PLASTIC <br />99.OIS eel <br />11I! <br />PIPMC�1'VRBRfB COMNNT.rzM SUMP Trig t.SINGLE WALL E. DOUBLE WALL <br />4 k <br />90, NONE <br />VL VENT, ER. /FILLPOE PIPiI+(GCONS'T'RUCTION <br />I <br />VERA PRIMARY COMAINMI!NT 1. STEEL <br />{. P183AGLA$S ID. RIGID PLASTIC O.NON6 99, VD1ER(spenh) <br />VEMSECONOARYCONTAINMENT <br />16111 <br />t. STEEL 4. FIBFAOl.A99 IO,,NGIDPLASTIC .NONE 99, OTHERS <br />VR (Pec11Y) <br />46111 <br />1011 <br />PIUMARY CONTAINMENTIj I. STSEI. /. FIHEAOL 10. VOID PCA9TIAll <br />C <br />V.NONE 99. OTHER(Spec:fPl <br />RSECONDARYCOMAINMgNT I. STEEL /. F18ERaLAS7 I0.1U01OPLASTIC <br />64! <br />1Y 1 <br />. NONE 99. OTHER (3pKily) <br />YETM TAA rIT $UMP TYPE I.SMGLEWALL <br />RISfiR PAMAAY CONTAINMENT 2000BL6 WALL <br />4/4S <br />IH01 <br />,Npryg <br />1. STEEL /. MHEROLASS ID. MOLD PLASTI NONE 99.OTHER iSpae:h) <br />Me <br />WSMSECONOARYMNTAMMfiM 1.51756E 4. FIHEROLASS ID. RIGID PLASTIC NA <br />ONE <br />96V <br />I <br />W. OTH6A(Speeify) <br />FILL COMPONENTS INSTALL nD I. SPILL BUCKET 3. STNIXER FLATMOTTOM PAOTHCTOR <br />161k <br />/. CONTAINMENT UMP <br />VII. UNDER' DISPENSER. CONTJAINM NT (UDC <br />CONSTRUCTION <br />�161k1 <br />TYPE ❑ I,SINGLEwAU,. Qz. DOUBLH WALL D'NO DISPENSDRS 9R NONE <br />CONSTRUCIDONMATBRfAGI.STEEf. <br />ON <br />4.PmERGLASS IO.RIGIDPLASTIC ❑ 99.0T71EA S M <br />V III. CORROSIO PROTECCION <br />u96c <br />. <br />STEEL COhVONENTPA075C170N O Z. SAgtlf[CIAL ANODE( ❑ 4.IM11ESSED CURRENT <br />L] 6. ISOLATION <br />eec <br />IX. APPLICANT SIGNATURE <br />CERnFIC,AnON: I certify thole 111116 UST oil 611eIII II I:emIII tl 1 11 wllh the hazAPdou! 6pb6tRnce 64ercd Rod that <br />, and In Rall mm Ilnnee wlth I RI r dremenp. <br />the In[ermatloD prwldad han1A h tne, <br />lilice <br />APPLICANT SIGNATURE - <br />DATE / <br />.A u. <br />APPLICANT NAME(prilit)TC <br />nl.LMM <br />/ G �•I <br />UPCF UST•E • 1/2 <br />