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UNIFIED PROGRAM CONSOLIDATED FORM �� 05 ?� g� � <br /> j <br /> COPYUNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) <br /> i'YyT: OF ACTION ( Check one Item onlp. For an UST permanent closure or removal. complete only= this section and Sections 1 . 11, 111, IV, and iX helox% 4110 <br /> 1 . N'1:\\' PERMIT 133. RENEWAL PERMIT ❑ S . CHANGE OF INFORMATION <br /> ❑ 6. •TEN•IPORARY UST CLOSURE ❑ 7. UST I)CRi14ANENI' CLOS1.1R1a ON SITE ❑ S. UST REMOVAL i <br /> DATI UST PERMANENTLY CLOSED: 131a DATE EXISTING UST DISCOVERED. 430b <br /> 1. FACILITY INFORNIATION <br /> FACILr1Y ID # (_iger)cl• ( 'se (inti! - 1 <br /> BUSINESS NAME ( Same as FACILITY NAME or DBA- )oing Business As � �C � ' a � <br /> P N 90L NQ foS i MC . I <br /> 1sT, s srrE ADD s5 - - 11,; cITY <br /> / z S - €�SCAL eON AVE -e ctckt -ow <br /> 11. TANK DESCRIPTION <br /> I-ANK [I) A TANK MANUFACTURER 43; TANK Cam-fti mea-riOK: Tim rAN&x is 434 <br /> 1 STAND-ALONE •TANK <br /> 2. ONE iN A COMPARTItENMED UNI'r . <br /> Cum tcto ono race for each com anmrat m the unit. 1 <br /> DATE t IST SYSTEM INSTALLED 43g I:ANK CAPA TYING LLONS 436 NUMBER OF COh•IPAR'TMENTS T1 THE UNIT 13' <br /> III. TANK USE AND CONTENTS <br /> T,\ NK USE fa. MOTOR VEHICLE FUELiNG ❑ ib. MARINAI'VELING J ❑ Ic. AVI.A170N FC- I-I, \G <br /> ❑ -i . CliEMICAL PRODUCT STORAGE ❑ 4 . IiAZARDOI;S WASTE (fndudts Used 03) ❑ 5. MOERGEN'C'Y GENERATOR FUEL IILSCf353S1 Reel <br /> ❑ 6, OTHER GENERATOR FUEL ❑ 95. VNKNOWN ❑ 99. OTHER (Specify): �?`> <br /> CON TENTS PETROLCUNI , ❑ ) a. REGULAR UNLEADED ❑ Ir.. MIDGRADE Ib, PREMIU&I UNLEADED <br /> ❑ :. DIESEL. ❑ 5. JET FUEL ❑ 6. AVIATION GAS <br /> ❑ 8, PETROLEUM BL 3ND FUEL ❑ 9j OTHER PL- TROLEU\i (Specifif): 440a i <br /> NON-PE'TROI EUM: ❑ 7. USED OIL ❑ 10. FTHANOL <br /> ❑ 1 I OTIiER NON-PETROLEUIV (Specify): 440b <br /> IV. TANK CONSTRUC PION 1 <br /> TYPE OF TANK ❑ 1 . SiNGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 843 <br /> PIUMARY' CONT;AIMMENT ❑ I . STEEL ?, FiBERGLASS ❑ 6. INTERNAL BLADDER 444 <br /> ❑ 7 STEEL - INTERNAL LINING ❑ 95 UNKNOWN ❑ 09, OTHER isped6fl. 4441 <br /> SF:C ONDARY` CONTAINMENT ❑ I . S-TEFL a. FIBER(JiLASS -❑ 6. EXTERIOR MENIBRANE• LMIE• R ❑ 7. dACKEPTED 445 <br /> ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER ( Specify=): 4458 <br /> OVERFILL. PREVENTION ❑ L AUDIBLE t VISUAL AL ARMS 0 2. BALL FLOAT ❑ S. FiLL TUBE SHUT-OFF VALVE 4. <br /> ❑ 4. TANK ATEETS RE()UIRL• AiENTS FOR EXEMIATIOI+' FROM OVERFILL- PRRVEN'TION HnI VNIENT <br /> _ V, PRODUCT / WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTiON ❑ L SiNGLE-WALLED _. DOUBLE WALLED ❑ 99, 00rI-tut <br /> SY'S'I'Eki TYPE I . PRESSURE ❑ ?. GRAY fTY ❑ ;. CONVEN'TiGti\ t_ SI CTiO\ ❑ A. SAFE St ;C1'ION 133 CCR _63c(slf3j 4s <br /> PROofARY CONTAINMENT 1 . STEEL 14 4tFIBERGLASS ElS. FLEXIBLE ❑ 10. RIGID PLASTIC 4ij4 <br /> ❑ 90, NONE ❑ 95. UtitvEOWN ❑ 99. OTHER(Spec4): 4a):; 1 <br /> SECONDARY C(ENTAINMENT ❑ 1 . STEEL 4 . FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4640 1 <br /> ❑ 90. NONE ❑ 95 . l NKkNOWN ❑ 99. OTHER (Specify): 4648 2 <br /> PIPINGTURBI-NE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL. W2. DOUBLE WALL. ❑ 90. NONE 4644 <br /> Vl. VENT, VAPOR RECOVERY (VR) AND RISER I FILL PIPI PIPING CONSTRUCTION <br /> \T NT Pit INtARY CO\TAI \:(IENT ❑ I - srrEL X4. FIBERGLASS ❑ 10. RICTID PLASTIC p 90. NONE ❑ 99. 01 H>;R (Silwif -) + <br /> 41�tu ( <br /> \'Ei'f SECONDARY" CON T:Y }\\ fEN'f ❑ 1 . STEM. 4 . FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99, OTHER (SpL66 ) 4i;1 I <br /> 46491 ! <br /> \'R 1'Rl IARY' CONTAi\4) L\1' ❑ I . STEEL 4. FIBERGi_ASS ❑ IQ RIGID PLASTIC ❑ 90. \O\F. ❑ 99, OTHER ($peal}•) 464;' <br /> 464 -1 l <br /> VR SECONDA RY CONTAINMENT ❑ i . STEEL fW4. FIBERGLASS ❑ 10 . RIGID PLASTIC ❑ 90. ?NONE ❑ 99. OTHER (Specify) 4641: <br /> 464n 1 i <br /> \'Emk PIPING -mANSiTiON SUMP TYPE . ❑ 1 . SINGLE WALL Lk 2. DOUBLE WALL ❑ 404 NONE 464i 1 <br /> RISER PRiMARY CONTAINMENT PC 1 . STEEL_ J. FIBERGLASS ❑ 10. RiGID PL.AS77C ❑ 90. NONE ❑ 99. OTHER ( Specify) 4641 <br /> 464i1 <br /> RISER SECONDARY CONTAi\NIENT ❑ 1 . STEEL "$Zd. FIBERGLASS ❑ 10. RiGID PLASTIC ❑ 90. NONE ❑ 99 OTIiER (Specii}') 4641 <br /> 464k1 1 <br /> FILL COMPONENTS iNST.ALLED i . SPILL BUCKET .,. S'rRiKT.R PI,A'rEBOTTO'(i PROTIiC"1-OR 4 . CONITAI \A•IEN'r St !4fP 4Sia-r <br /> VIj* UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ❑ i . SINGLE WALL X2, D0118LE A'ALL ❑ 3. NO DiSPENSERS ❑ 909 NONE =16fa <br /> CONSTRUCttON MATERIAL ❑ I . STEEL. W4, FIBERGLASS _ ❑ _10. RIGID PLASTIC ❑_ 9a, OTHER (Spccifi_ ) ;6 6 <br /> VIII. CORROSION PROTECTION <br /> s'1'EF). C()Sii'Cii, EN"i' PROTE{"fiOY ❑ 2SACRIFICIAL \\ODE(S ) ❑ 4, IMPRESSED CURRENT X(1. ISOLATION 448 <br /> IX. APPLICANT SIGNATURE , <br /> CERTI FICATION : I eertlfy that fids UsT system is compatible ~with the hazardaus substance stored and that the informadm) provided herein is true, accurate, <br /> and in fill [ compliance with legal requirements. <br /> APPLICANT SIGNATURE DA'L'E <br /> APPLICANT NAME (print) 471 APPLICANTTTT'LE 1 478 <br /> _ t <br /> t11C ' F' UST-13 - 1 /2 Rey. ( 12,12007) <br />