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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK + <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (OmformvaT /Z <br /> TYPE OF ACTION (Check one item only. Fora UST closureor removal,complete only this section and Sections 41f,111,1F,and 1X below) <br /> [3 I.NEW PERMIT ❑ 3.RENEWAL PERMIT 3.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. I DATE EXISTING UST DISCOVERED: 430e_ <br /> I. FACILITY INFORMATION <br /> FACILITY ID p(Agency Use Only) <br /> BUSINESS NAME(Sense m Facility Name or DBA-Doing Business As) ' <br /> R1ve%- Fbtr +- ),clvkiklye, rlrclnck <br /> BUSINESS SITE ADDRESS <br /> II. TANK DESCRIPTION <br /> TANK ID R 432, TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> 1.ASTAND-ALONE TANK cmplacoee"furr <br /> TA O IU 2-S U5 �Yv SC C) Z ONE TN A COMPARTMENTED UNIT cvmpam cot m d - <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 4% NUMBER OF COMPARTMENTS IN THE UNIT -11 <br /> (y Cwp anu <br /> IIL TANK USE AND CONTENTS <br /> TANK USE L] Is.MOTOR VEBCLEFUETSNG R Ib.MARINA FUELING l] Ic.AVIATION FUELING 439 <br /> HE . <br /> (] 3.CMICAL PRODUCT STORAGE 4.HAZARDOUS WASTE Wd Oil) L] S.EMERGENCY GENERATOR FUEL ft6C MIS <br /> ❑ &OTHER GENERATOR FUEL [195.UNKNOWN ❑ 99.OTHER(Speeify). 434.. <br /> CONTENTS PETROLEUM: [3 IU REGULAR UNLEADED Ic.MIDGRADE UNLEADED (] Its.PREMIUM UNLEADED 4np. <br /> (] 3.DIESEL 3.SEF FUEL (1 6.AVIATION GAS <br /> (1 8.PETROLEUM BLEND FUEL 9.071m PETROLEUM(Spcmfy) _ <br /> NON-PEIROL.EUM:137.USED OIL 10.ETHANOL <br /> ❑ 11 OTHER NON-PFTRDLEUM(Speci410a <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK �( I.SINGLE WALL 2.DOLBLE WALL ❑ 95.UNKNOWN N3. <br /> PRIMARY CONTAINMENT ,B I.STEEL ❑ 3.FIBERGLASS 136.INTERNAL BLADDER 444. <br /> 137.S[EEL*INTERNAL LINING (] 93 UNKNOWN (]99.OTHER(Epecly): seen. <br /> - - <br /> SEOONDARYCONTAINMENT O 1.SIEE. ❑3.FIBERGLASS (] 6.EXTERIOR,MEMBRANE[LINER ❑ 7.IALTCEIFD .�. <br /> Q 90.NONE E3 95.UNKNOWN X99.OTFBR(Sp4cifYTF b.-+-al°'.SS cut-t�.Q Sfc.-1.4w <br /> OVERFILL PREVENTION (] 1.AUDIBLE&VISUAL ALARMS 11 2.BALL FLOAT 3.FILL E SHUT-OFF VALVE 4>z <br /> El 4.TANK MEETS REQUIREMENTS FOR RXEMPf1ON FROM OVERF LL PREVENTION UH%am <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> _PIPING CONSTRUCTION 1.SINGLE WALL2.DOUBLE WALL _Q 99.OTllER <br /> SYSTEM TYPE $•I.PRESSURE -(ag1 2.GRAVITY Q I.CONVENTIONAL SUCmlN ❑ 4_SAFE SIICIIONjH� <br /> PRIMARY CONTAINMENT (] L STEEL ----- 4.FBERGIASS () 8.FLEXIBLE L] 10.RIGID PLASM 4+4. <br /> 90.NONE_ (] 95.UNKNOWN (] 99.OTFBR(Sped ): 464a <br /> SECONDARY CONTAINMENT O 1.STEEL AX4,FIBERGLASS O 8.FLEXIBLE (] 10.RIGIDPLASTIC 464ti <br /> (] 90.NONE I] 95.UNKNOWN_ 0".OTHER(Specify): 4646 <br /> PIPING(TIJRBINE CONTAINMENT SUMP TYPE JZ 1.SINGLE WALL 13 2.DOUBLE WALL E3 90.NONE 464k <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS (] JO.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): N43- <br /> VENT SECONDARY CONTAINMENT El 1.STEEL O 4.FIBERGLASS (] 10.RIGID PLASTIC , C90.NONE ❑99.OTHER(Specs&): <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL._ ❑4.FIBERGLASS O 10.RIGID PLASTIC $90.NONE (] 99.armit Speciry): <br /> VR SECONDARY CONTAINMENT (] I.STEEL (]4.FIBERGLASS (] 10.RIGID PLASTIC jg9&NONE (]99.0T ER(Spedfy): - <br /> VENT PIPING TRANSITION SUMP TYPE (] L SINGLE WALL (]I DDUBLE WAIT 90.NONE �. <br /> RISER PRIMARY CONTAINMENT 1.STEEL (]4.FIBERGLASS (] 10.RIGID PLASTIC G 90.NONE (7 99.OTHER(Spedry): �t� <br /> RISER SECONDARY CONTAINMENT 1] 1.STEEL. 134.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE (] 99.OTHER(Speab): Nott. <br /> FILL COMPONENTS INSTALLED .SPILL BUCKET ja 3,STRIKER PLATErBOTTOM PROTECTOR 4.CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE 1.91NGfE WAIL 2.DOUBLE WALL O 3.NO DISPENSERS 13 90.MICE <br /> CONSTRUCTION MATERIAL. 1.S[REL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC (] 99.OT HER(Specify) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANO 5 4,IMPRESSED CURRENT 19 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th his T ryatem is compatible with the hazardous substmce stored and that the information provided herein is true, <br /> accumt i lf 'ante with le al re uiremena <br /> no <br /> APPLICANT SIGNATURE DATE 41117)7- <br /> APPLICANT <br /> IT IZAPPLICANT NAME(pnnt) APPLICANT TITLE 4n. <br /> A*JORc-+-1 �L;;ri(Sc¢C MA-a-, ^^kr.r'Az�CIL <br /> UPCF UST-8 Rev.(I2t2007)-1/2 www.unidoczorg <br />