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X <br />E4 <br />05/20/2009 13:53 209464FI138 <br />ENVIRONMENTAL H ALTH <br />11.01 <br />PAGE 03/04 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPIrRATINGPERMIT APPLICATION- TANK INFORMATION Onefolm US <br />PE OP ACTION (Chcok one item only. For UST parnime it oloSM of tehKiY , cOnV1812 anly this ueti0n and $actions 1, IT, III, TV, and IX below) <br />sess"13 <br />m. <br />LNEWPERMFT 3. RENEWAL PERMIT ❑ $.CHANGE OF INFORMATION <br />6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE . UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: R'AW "t" I DATE EXISTING UST DTSCOVEREDI <br />1. FACILITY INFORMATION <br />FACILITY ID 8 (Agency UYe Doly) <br />u <br />, <br />BUSINESS NAME (Same As FACILITY NAME at DBA•D64ag Business As) <br />c/9� J <br />EU$ S C 'm <br />CTFY ST C/L 7oili <br />IL TANK DESCRIPTION <br />TANK TO = <br />TANR MANUFACTURER +SS <br />TANA CONMaumAmm; TRIS TANK IS <br />+34 <br />-z9�/� <br />-,o 579 <br />(/,t%r�iIIQGl� <br />�A STANP•ALONB TAM <br />Ei.ONEMACO,MPAATMENTEDUNIT. <br />DATE UST 3'($TEM ID7ST ED +a+ <br />(//✓K <br />W��'VVV <br />TANK OAPACI7•Y LLONg <br />dem. fm ach mtln Neun�r. <br />NUMBER OF COMPART N THE UNIT <br />+�I <br />Ci/ <br />AIAe'I`,A A.M USP)AkID CONTENTS <br />TANK USE MOTOR VEHICLE FUELING ❑ lb.MARNAFUELNG Cl Ic AVfATIONFUMNO <br />❑ 3.CHBlCAL PRODUCT STORAGE <br />+J) <br />❑ A. HAZARDOUS WASTE (I h&o Ue " ❑ S. EMERGENCY GENeRATOR MEL(N6CtiQSIJ(.)] <br />❑ 6.OTHERGENERATOR FUEL ❑ 93. UNKNOWN <br />❑ 99.OTMR ( i ; <br />CONTENTS PfiTROL6UM: ❑ Ic REGULARUNLEADE1 ❑ Ie. MII)GRADE UNLEADED ❑ Ib. PR13d1UM UNLITADED <br />+39. <br />❑ J. DIESEL ❑ S. JET FUEL ❑ 6. AVIATION GAS <br />❑ S.MXOLEUMBLENOPUSL ❑ 9.OTHER PETROLEUM g i <br />IW <br />/V{Xy <br />NON•PETAOLEUM: ❑ T. USED OIC ❑ 10. ETHANOL <br />MOJ <br />1I.OTHFA NON•PETROLEUM <br />1146 <br />IV, TANK CON <br />TYPE OF TANK SINGLE WALL 2.DOUBLE WALL 95. UNKNOWN <br />PIUMARYCONTAMMENT •STEML ).FIBERGLASS 06, INTERNALBLADDER <br />MJ <br />7. STEEL+MTERNAT. LTNMG ❑ 9f.UNKNOWN 1] 99, GtwA <br />cif <br />SECONDARY CONTAM6IENT ❑ I. STEEL J. FIBERGLASS ❑ 6. e%TIiR10R MEMBRANE CHER ❑ 7. JACKETED <br />e.y <br />.NONE 93.IlNRNOWN ❑99. U61- 9 -Ifyin <br />OVERFILL PREVF1f00N 1, AUOUAR R VISUAL ALARMS 2.BALL FLOAT <br />1. FTLLlTJ881tIGJTAPP VALVfi <br />(3 4. TANK MEETS REQUIREMENTS FOR 9XLWPT70N PROM OVERFILL PREVENTION EQUIPMENT <br />V. PRODUCT/ WASTE PIPING CONSTRUC=TION <br />PIPING CONSTRUCTION M 1. SMGLE•WACLEO ZOOUBLbWALLBD ❑99.OTHER <br />SYSTEM TYPE I.➢RESStIMS 2.ORAVT' NYFMTIONAL SUCTION A.SAF6 SUCTION LLCR 6J <br />PRIMARY CONTAINMENT 1. STEEL ❑ 4. FB ULA33 ❑ 8. FLEXIBLE <br />eta <br />❑ 10. RIGID PLASTIC <br />❑ 90. NONE ❑ 93. UNKNOWN ❑ 99. GTE ER ecib : <br />161 <br />SECONDARY CONTAINMENT I. S LJ 1. FIBERGLASS Ll B. FLEXBLE 10. RIGID PLASTIC <br />964 <br />NONE O 95. UNKNOWN ❑ 99, OTySR S cel <br />46@ <br />PIPMGTJRBINRCONTNNMENTSUMP TY➢E 1.SMGLS WALL 2. DOUBLE WALL 90. NONE <br />, <br />VI, VENTP VAPOR RECOVERY (VR) AND RISER. /FILL PjfE PIPING CONSTRUCTION <br />VENT <br />esad <br />PRIMARY CONTAINMENT 1. $TEE[. I. FIBERGLASS 10. RIGID PLASTIC .NONE Q 99. DTTTBR (6p¢ib) <br />161e <br />VENT SECONDARY NTNNMENT t. STEEL A. FIBEAGLA99 10. VOID PLASTIC .NONE 99, OTHER(SFeclly) <br />IlHaeit <br />VR PRIMARY CONTAINMENT I] I. STEEL ❑ a. FIBERGLASS 11 IO. NOLO PLASTIC NCNE Q 99. OTHTsk (SpeeifY) <br />161e <br />VKSECONDARYCONTAMMENT I. STEEL e. FIBERGLAS$ IO.NOID PLASTIC . NONfi 99.01'NBR (Spaei/yI <br />�' <br />1616 <br />VENT PIPMGTRAN3T $UMP TYPE I.SNGLE WALL 2. DOUBLE WALL .xDNe <br />AI$ER PRIMARYCONTAMMENT 1. $TEFL <br />will <br />+. FI8fiA0LAS9 10. MOTU PLASTIC47 <br />99.GIHUR(Spedry) <br />AISNI SECONDARY COMA[NM6NT 1. STEEL a, TlB1iROLASS 10. NO1D PLASTIC , NONE 99.011I PeeifY) <br />/61k <br />FILL (X)M➢ON6NTS INSTALLED 1. "ILL BUCKET 3. SINKER PLA1F/80TTOM PAOTECTOA A, CONTAINMENT' SUMP <br />SU <br />VII• UNDER DISPENSER CONTAINIIIEN f (UDC) <br />9J�c <br />CONSTRUCTION TYPE 13 1. SINGLEWAµ ❑2, WUBLE WALL ❑3.N0 O1$PPNSI;RS <br />CONSTRUCDON MATERTAL ❑ 9R NONE <br />WY. <br />7. gTYEI, 4, pIBERGLASS <br />❑ 10.NGID PLASTIC ❑ 9g, UT{IER ai <br />. <br />VIII• CORROSTONPROTECTION <br />Ic96e <br />STEEL COMPONEN7PR0TB--- ❑ 2.SACRIFICIAL ANODE(S) LI I, IMPRESSED CURRENT ❑ 6.I3OLATION <br />�+Ic <br />IX. APPLICANT'SIGNATURE <br />CERTIFICGATION: I « rt)ry that {OIs UST system H "Wisotibla with the haardous sobstanee stored Red that the IBT6rmeHoe <br />And In Iltlleo IBlnce with Air drethenes. provMed erred, It tree, <br />aeemitq <br />APPLICANT SIGNATURE DATE <br />APPLICANT NAME Witt) + 1.- <br />i TTjJ,.E <br />I <br />, <br />/ <br />1/ <br />. <br />UPCF UST•B -1/2 <br />OF <br />� Rev. <br />� <br />