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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(Orte fomper UST) <br /> �PF OF A(I"LON (Chock unc item only. fix an UST permanent closurc or removal,complete only this section and Sections 1,11,111,IV,and IS bolo vl 410 <br /> I.NEIN PERMIT [01RENEWALPERMIT ❑ 5.C11ANGE OF INFORMAT(ON <br /> 6.TEMPORARY LIST CLOSURE 7IISI PERNIANENTCLOSUREON SITE 0 IL USTRIARIVAL <br /> DATE LIST PERMANENTLY CI.OSEI): 3141 I DA TE EXISI"ING UST DISCOVERED. 4145 <br /> I. FACILITY INFORMATION I <br /> FACILITY ID P(Agent)Use OufT) _ _ ' /„ 171 <br /> 1 <br /> BUSINESS NAME(Stmle4s FACILITY NAME.or DBA-Doing Business As) C� 1 <br /> EAST HARNEY ARCO <br /> BUSINESS Sl'I'L'ADDRESS Irl CITY <br /> IfY LODI 111 <br /> 255 E.HARNEY LANE <br /> 11.TANK DESCRIPTION <br /> TANK IDS 412 TANK MANUFACTURER 4]] 'I-ANK CONI 161 RKrION: 'BRS TANK IS 414 <br /> ❑ I.A SAND-ALQ%E TANK <br /> 3 XERXES •,Inst m,L,ONI i� SART\I�E'NmEO�.11 <br /> DATE UST SYSTEM INSTALLED 4Fs 'TANK CAPACITY IN GALLONS 4.16 NUMBER OFCOMPARIMENT'S IN TIIE UNIT 4I' <br /> TBD 10,000 2 <br /> 111.TANK USE AND CONTENTS <br /> TANK USE M Ia M.01OR VEHICLE FUELING I] Ib \IARIN.A I IIIJAVO ❑ Ic.AVIATIONFUrIANG 4t4 <br /> ❑ 1CHENtICALPRODUCTSTORA61. ❑ 4.I IAZARDOUS WASTE IIndad Uwd Cal] ❑ S.LMERGENCY GENERATOR FUEL PfWt252415wj <br /> [16 OTHER GrNFRArOR FUEL ❑ 95.UNKNOW'.\ ❑ 99.OfHER( i ). 43"e <br /> CONTENTS PE rROLEUM ❑ la REGULAR UNLFADF D ❑ la MIMMADEL'NLEADED O I b.PREAIIUMUNLE.ADRD 44:, <br /> l INIMPI. ❑ 5.)F.T FUEL 0 6.AVIATION GAS <br /> a Pt7ROLLUNI BLEND FUEL 0 9 OFHiSR PF.TROLIA SI (SPC66).: um <br /> NON-PHROLELIM:❑ 7.USED OIL ❑ lO I-IIIANOL <br /> 1 OTI ANON-PHIRUi.EU\I IS'nwifi). N01, <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TAKK LSINGLE{L'ALI. 12.DOUBLEWLALL ❑ 95.Ila KNOWN u5 <br /> PRINT ARY CONI AINMENT L71.STEEL N ?.HBERGLASS ❑ 6.INTFRNAI.RI ADDER 444 <br /> ❑ ?.SI ETL*INTERNAL I.INING ❑ W.UNKNOIAN ❑ 99.OTHER IspcofO 4Lt4 <br /> NI:fONUARy CO NLAIN\IE]T ❑ L 0 1 FIBERGLASS ❑ 6.G\"fER10R MCUHR ANE LINER ❑ 7.IACKETE.D 445 <br /> 90.NON I, ❑ 95.UNKNOWN 9901'1Ek(S -ifi 4n4 <br /> OVERFILL.PREYFNTION f.AUJAHLE S I'ISl1AL.OIL ARMs 2Ib11.1.MET! 0 t,FILL TCBESIILT-OFF%'A[1'1' 452 <br /> ❑ 4.TANK\IT M. RII;jUlliliMF.NTS foR EXEMPTION FROM ONTRFILL PREVENriON LQI Ivmt,NT <br /> V. PRODUCT I WASTE PIPING CONSTRUCTION <br /> • PIPING CONSTRUCTION f.SIN(iLk?R'ALLEO 2.DOU61&W"AL.7.FD 990'OIER 4e9 <br /> SYSTENiTYPE 1 PRI'S9L'RI: ❑ 1GRAVITY ❑ 3.CON'VI:NrIOXAI.SUCOON ❑ 4SAFE SUCTION 1.11 CCR 1=6115(wir 454 <br /> PRIMARY CONTAINNIL'NT ❑ I STEEL E 4.FTDERGLASS ❑ H.FLEXIBLE 10 RIGID ITASI'IC 4. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTIIFR(SPeafi) 4wa <br /> SI:('OM)ARY CONTAINMENT 13 1 sw1 0 4.FIBERGLASS ❑ R II.ICN11H.1. ❑ IO.RIGIDPLASI"IC 4&IN <br /> ❑ 90 NONE: ❑ 9$.UNKN'OW'N 13 99 OI HER(Slmcify). 4a <br /> PIPINGTLIRBINF.C'ONTA]NNIEN1'SUMPINPE ❑ LSINGLRWALL 0 2.DOUBLEW'ALL. ❑ 9a NORG 4e44 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> Y1:NTMwARY CONTAINMENT ElI.STEEL 4.FIBERGLASS O Ia.RIDIDPI.ASDi' U 'A'.NOSE [I" OT11FR(Sp.6fl) Owe <br /> 4wel <br /> %TNTSECONDARYCONTAINNIENT 1 S1'If1:L E 4.FIBERGLASS ❑ 10,RIGID PLAS IK 0 90.NONE 99 OTHER(SPwr)) 4wr <br /> 4wr1 <br /> VRPRIMARY(TW'I'AINSIENT ❑ I STI'T'1. E 4.FIBERGLASS D I O.RIGIDPI.ASIIC 0 'XI NOSE 0 99.OTtIER Opwff[) 4644 <br /> 4w�I <br /> VIC SECONDARY CONTAINMF.N'1 ❑ 1 STEEL a 4 FIDERGLASS W.RIGIDPLASTIC 0 9(1 NONE'- 99.OTIIFR ISpeci(y) 4o4h <br /> 4wh I <br /> \'IiNT PIPING TRANSITION SUMP TN PE LSINGLEWALL E 2.DOUBLE WALL 90.SONF: 4a4' <br /> RI SE R PR I MAR Y CON TAI-\:\1ENT ❑ 1,STEEL 0 4.tIBERGLASS U 10 RJ/11UP-kSlIC 8 90.NONE O `>9.07MIFRISPmfe) 4541 <br /> 4w 1 <br /> RISER SECONDARY I'OSfAI,NMENT ❑ I,NTlail. 4 FIBI:RGL.ASS [I 19.Rtti)D M.:\SI1C 90.NONE X99 pT11ER(SPnikl 4wt <br /> dwtl <br /> FILL COMPONENTS INSTAL1.11) LSPR.I RtCKCT E t.SIRIKLRPLATEBOTTOSIPRo'iu(uoR E 4.CONTAINSI(:NTSU\IP 4114+' <br /> VIL UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRU(-nON'i1TE 0 I SINGLE WALL 2.L7t)CBLE WALL L3 ] NO IHSPF.NSERS ❑ 90 NONE 4cva <br /> ('(1NNTRt[('ODN MATERIAL ❑ LSTEEL 4 IIBIIRGLAti ❑ 10.RIGID PLAST[(t 7YI.OIHLRIS -IR) �. <br /> VIII. CORROSION PROTECTION f�42 <br /> SIMLCOMPONENTPROTEC1'ION [I 2.SACRIFICIAC ANODE(S) L] 4 1NIPIMSSEDCURREN7 ❑ 6 ISOLATION •^ 1 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION! 1 cer(ifv that Ibis UST system is compatible with the harardous substance stared and that the information provide 'Awwo,Is Iraq accurate, <br /> and in full compliance Aids legal nrAuirrmcnM <br /> APPLICANTSIGNATURE ] DATE 4TM <br /> a( 1 c 3 I L <br /> n1. APPLICANT TITL 4.' <br /> 1'nl <br /> APPLIC,IA-f N.41�1E 1P ) j <br /> r T2.A71 <br /> UPCF IIST•R-SIE Be*,(12124)n4) <br />