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UNIFIED PROGRAM CONSOLIDATED FORM / <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per USI) 111 <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section❑ SHANGE OF INFORMATION and Sections 1,11,111,IV,and kX bel D <br /> F11.NEW PERMIT [13.RENEWAL PERMIT' <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ® 8.UST REMOVAL 43 <br /> DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 1(/11/2013 <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) - <br /> 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> Levand Family Trust 103 194 <br /> BUSINESS SITE ADDRESS CITY <br /> 47 East Eleventh Street Trac <br /> 11.TANK DESCRIPTION 414 <br /> TANK ION 3 433 TANK MANUFACTURER 413 TANK coamlGURA ]ON: Tws TnNKIs <br /> unknown ®1.A STAND-ALONE TANK <br /> !,� _ O ❑2.ONE IN A COMPARTMENTED UNIT. <br /> Cr.leeanea a for each. art.o.t i.the it. 437 <br /> D TE UST SYSTEM INS ALL,D 435 TANK CAPACITY IN GALLONS 436 1 UMBER OF COMPARTMENTS IN THE UNIT <br /> unknown 1,000 <br /> III.TANK USE AND CONTENTS 439 <br /> TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include Used(TI) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L5(ch 4391 <br /> Ll 6.OTHER GENERATOR FUEL ® 95.UNKNOWN ❑ lb.OTPREMIUM(Specify):UNLEADED 440 <br /> CONTENTS PETROLEUM: Ll la,REGULAR UNLEADED ❑ SJETL PUELDE UNLEADED O bbAV1AT10N GAS <br /> ❑ 3.DIESEL El FUEL <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.01IIERPETROLEUM (Specify)'. unknown petroleum <br /> NON-PETROLEUM:❑ T USED OIL ❑ 10.ETHANOL 440E <br /> ❑ I I.OTHER NON-PETROLEUM(Specify). <br /> IV. TANK CONSTRUCTION <br /> 443 <br /> TYPE OF TANK ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 95.UNKNO\VN 444 <br /> PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBP,RGLA$S ❑ b.INTERNAL BLADDER 444a <br /> El 7.STEEL+INTERNAL LINING 1 95.UNKNOWN [199.OTHER S city): 445 <br /> SECONDARY CONTAINMENT' ❑ I.STEEL ❑3.FIBERGLASS El 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE ® 95.UNKNOWN ❑99.OTHERS "i }. 452 <br /> OVERF ILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ Z.BALL FLOAT ❑ 3.FILLTUBESHUT-OFF VALVE <br /> ❑ 4.'TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION 460 <br /> PIPING CONS"rRUCTION ❑ LSINGLE-WALLED ❑2.DOUBLE-WALLED ®99.OTHER 459 <br /> SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAPS SUCTION 123 CCR§2636(a)(3)] 461 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464a <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4fi0.6 <br /> SECONDARY CONTAINMENT [I1.STEEL Ell 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464c <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTIIER(SPceny): 464d <br /> PIPING/TURBINE CONTAINMENT SUMPTYPI ❑ LSINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> VI.VENT,VAPOR RECOVERY(VERRISER/FILL PIPE PIPING CONSTRUCTION 164 <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4 FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE N 99.O'T'HER(Specify) 4M4 I <br /> 4Mf <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.121310 PLASTIC ❑ 90.NONE ® 99.OTHER(Specify) 464f1 <br /> 4619 <br /> VR PRIMARY CONTAINMENT F] L STEEL El4.FIBERGLASS ❑ 10.RIGID PLASTIC EI k_515 NONE ® 99.OTHER(Specify) 464 1 <br /> 64h <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 1310.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify) 461,1 <br /> 2.DOUBLE WALL ❑ 90.NONE 4M` <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [1464j <br /> RISER PRIMARY CONTAINMENT ❑ USTEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify) 4641 <br /> 464k <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ® 99.OTHER(Specify) 464kl <br /> FILL COMPONENTS INSTALLED ❑ I.SPILL BUCKET ❑ 3.STRIKER j: ::: :BOTTOM PROTECTOR ❑ : CONTAINMENT SUMP <br /> 4511-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.N0 DISPENSERS ❑ 90.NONE <br /> 696-c <br /> CONSTRUCTION MATERIAN I.STEEL El 4,FIBERGLASS ❑ 10.RICID PLASTIC ❑ 99.OTIIFR(Specify) <br /> L. <br /> VIII. CORROSION PROTECTION 449 <br /> S I FEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this LIST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, <br /> and in full compliance with le al re uirements, azo. <br /> APPLICANT SIGNATURE DATE 10/11/2013 <br /> an. an. <br /> APPLICANT NAME(print) Robert Marty APPLICANT TITLE Agent for Levand Property Trust <br /> Rev.(12/2007) <br /> UPCF UST-B-1/2 <br />