|
12/22/2011 15:08 2094640138 LNVIKUNMm N PL N6 n -•v- -- -
<br /> S�--
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMPC APPLICATION-TANIC INFORMATION lcM fi"O US r)
<br /> TYPE OF ACnON (Check 9P.item only. For m UST nmrclll cI9FJRe or amovd,<ompleH only this 9eeti0n A*d Sections I.II,TIL N,and i)(bl10W)
<br /> ❑ 1.NEW PF.Rl.Ui ® 3.ItF?NEVYALPGRMIT ❑ S.CHANGE OF INFORMATION
<br /> 6 TEMPORARY UST CLOSURE T UST PERMANFN7 LOSURE ONSITE 0 S.LIST SITS
<br /> DATE UST PERMANFNMY CLOSED DATE EXISTING UST DISCOVERED
<br /> 2(�nT 1pp'p:t @I T;(,•:If I Ts I ;)�j hPpR E ly�y7� I. sr A�:l(a ��R,vR�IAfi{�Fq;'J_ P ,
<br /> .,
<br /> FACILITY ID N(�ReJRY'um owy) M . 7,1
<br /> BUSINESS NAME(Same m FACILITY NAME w DBA-Do1Iqi2usiMSF F�J I •: A fgsop;url
<br /> BUSINFS6 ADDRESS 10! C)� _rrgs C
<br /> IAu4: ( 7XA1lt DESC' tiPT16Nl"'�', .,: •Il`Fti r ;1 ' :> +•
<br /> ���. ....,:-* v.,.,,:h..�� ra --1 .
<br /> TANK IDM TANK MA A R TANK CONPIGVIIATION 'iT)Ic rnNR IS ' ...
<br /> ©1.A STAN ALONE TANK
<br /> d Z
<br /> 93ONBMACOMPAXTMZI E UNIT. CE011 FE AOUINCO n
<br /> t s 3 70 ..... . ..� �M.�f.
<br /> DAYFUST§YSTEM TT4Si 4J1 TANK Y INALLONS 414 NUMBER OF COMPAR • S IN THE UNITRVrCEs
<br /> USH
<br /> .TANK USE
<br /> E".MOTOR RFOR r`Y.. Q .MAA mO AWA
<br /> HEWCM.PRODUCT STORAGE Q4,HAZARDOUS
<br /> WA7E OmMN .e01) 5.EMRGE+CI YGENERATOR
<br /> E..NERATOR ..
<br /> :.... . ..- <�t
<br /> FUEL IIQCpWLs(p1 Off•
<br /> Q 6.OTHER GENERATOR FUEL95.UNKNOWN ❑ ».OTHER(Sp...+
<br /> N[EYI$ PETROLEUM• O la REOULAR UNLEADED Q Ic MTDGRADE UNLEADED ❑ Ib.PREMIUM IMEADED
<br /> Er". 1E_cEL Q S.YET FUEL ❑ 6 AVIATION GAS else
<br /> Q 6.PETROLEUMBLIT"FUEL 9.OTf>ER 1'E7ROLEUM
<br /> NON-PE MOUM:Q T.USED O1L0 lo.ETHANOL ee0!
<br /> NONdmllOLEUM
<br /> e ,tX^I�i=', h^;t!ipIY4i,;..,,IY I.,TMx1� ,• ,;"'I
<br /> kNdNSYRUGT .1 ?
<br /> iYPP Ol TANKU I.SMOLE WALL UBLE-M.t. El M.UNKNOWN
<br /> PRIMARY CONTAINMENT TEEL ❑ S.FIBERGLASS ❑ 6.INTERNAL BLADDER 441a
<br /> Q T.STEEL 5 TNTEXNAL LNMG Q 95.VNKK09TN ❑ ».OTHER
<br /> SECOTIDARV COMAJNMEN7 I.STEEL BPRGLASS 6.EICTEIUOR MEMBRANE LWER ❑ 7.JACKETSD 41e
<br /> ❑ 90. ms
<br /> NONE El 95.UNKNOWN ❑».OTBF21 .
<br /> OVERFILL PRRVRNTION 1.AUDIBLE R VISUAL ALARMS 2.BM.L FLOAT .FILL TUBE 9HlR-OEP VALVE
<br /> ❑ STANK MEETS RE NTS FOR EnMPIION FROM OVERFILL PREVPN11ON Equalmsm
<br /> 'El,i�� y,r 1,�t�tY;(.(c 4'.'.�}f n.,.ve:•Y,?P�tdbUCl'f.WA576��IX�N CO1V'�TRUC'j'IOIY` ,-Y-I � w
<br /> CON97RI1L1TON 1.9MGI.PiwAL1.ED UBLEwnLtlD . '»,O7HER csf
<br /> sv47EM TYPE E3 I.PRESSURE rl 2.qjLAVrrY ].CONVENTIONAL SUCTION 13 4.SAFE SUCTION ID ca Ixf . f
<br /> PRIMARY CONTAD&ENT Q 1.STEEL .nVERGLASS ❑ S.FLEY(191,B Q 10.RIGID PLASTIC
<br /> Q 90.NONE Q93.UNKNOWN 99,OTHER 9
<br /> SECONDARY CONTAMMENi LSTEFY [.)TpIBERGLA99 Q RFLIVOSLE ❑ 10.RIGIDPLASnCrl c+eb
<br /> 6<
<br /> 90.NONE [3 95. KN
<br /> UNOWN C3 ».0T76R(S y
<br /> . ): .sb
<br /> PWMGYIT1RBfld CONE SIJMPTT}6jjrj.SMoLEWALL U F.DOUBLE WALL 1390.NONE
<br /> �;r��,��1, "�'�r ,Yt�;3�rYi,vA;P�_ REcoVi=RX J;►riD>iYiE»etLI.PUP>;rIPZPtNGcor��iPYIU�'1'lox , '
<br /> VENT PRAIMY CONYAIM.fENTerl,smE ..IIBERGLASS U 10.RIO.PLASTIC u 90.NUNL u .GTHEA(Sped
<br /> VENTSECONDARYCONTAiNMENT I.STRPL 4.FIBERGLASS 10.RIGID PLASTIC .NONE 99. E (S:Iy' mm
<br /> VR PRIMARY CONTAINMENT1.STEEL a.FIBERGLASS Ll 1°.RIOMPLASTIC ❑ 96.NONE U 99.OTHER( Pani )
<br /> VR SfiCONDARY COMAMMENT 1.STEN. ❑ •FIBERGLASS ❑ 10.RIGID PLASTIC .NONE 99.OT1 ( pedfy) SER•
<br /> 4_
<br /> VENT PIPING TRANSMaNr SUAR7YPE I.5G40LE WAL J.DOUBLE WALL 'NONE
<br /> RISER PRIMARY CONTAINMENT ❑ I.STEfO, e,FIBERGLASS 10,RIGID PSA9TIC NONE D0 (Specify) SWI
<br /> RISER SECONDARY CONTAINMENT 1,STEEL Q 4 FIBEF.GLASs Q 10.RIGID MASTIC 0,W.NONE E3 99.0 pe ) eW
<br /> eMb
<br /> PILL COMPONENTSINSTALLED J.STRIKER PLATSmurIOM O%CIOR 04.CONTAn4bWMTSLtMP 41.c
<br /> Ise,;'r„VII..UNDER DXSI$�ot CO e�,1NNl'aL�I!Tit131k:7-''�. `, ;...� •'� �`„ . 's:'ti
<br /> .. - . ....
<br /> IU,Ty" .SINGLE WALL 2.DOUBLE WALL 9.NppT9vt]4RCRS KNONR 4JRA
<br /> N MAT7RUAL 1 STEEL. / FIBERGLASS ❑ 10.RYOIDPLA TIC 0.
<br /> Ip � .0, � .y,,..� (.��y`..y�y� -yy�. uar .y: -. rrv,•' A. .,,. ...
<br /> .r%3Ni'�' !li ( ),1�fs� '}i•9�I,'FeYY�.l4�,:A. 1}.•(If:.f �R_R�?�!1�ffn.N��1i �V1�M 1J .: r�.yy�.Y v+i.�R'- •�l'L�•W''
<br /> SMMLCD?O,O ENr9ROTEQ 4.PQRES.MJI,�CU�9,ne'�RRENT QA ISOLATION
<br /> i J ... ,S 1 a;wW3,�NI Rerv' ;�.I. A,eI.... t 'fsf ..
<br /> TION: left"IMS 9RIf eyNem Y A9wprBRle wiUf Oe RRmeds.e e.bMra MRM PN Ma91Re iRMmRR..pw109d Rertlw ie bRll AtetmMe,
<br /> and M AI mmpfiam W:IR I I regmimmmts.
<br /> rn.
<br /> APPLICANT SIGNATURE. 11,
<br /> 11
<br /> 7E /Z ,
<br /> eN' APPLICANF TITLE
<br /> APPIXANC NAME(pruA) d
<br /> MY USF-B-V2 ,^ Rd.(ILNp7)
<br />
|