Laserfiche WebLink
V J <br /> UNIFIED PROGRAM CONSOLIDATED FORM q <br /> UNDERGROUNDSTORAGETANK D l� <br /> OPERATING PERMIT APPLICATION-TANK INFO <br /> RMATION (One fo mpe UST) <br /> E OF ACTION (Check one item only. For a(IST closure or removal,complete only this section and Sections I,II, IV,and 430. <br /> !/I, IXbefowJ / J <br /> ].NEW PERMIT El 3.RENEWAL PERMIT <br /> El 6.TEMPORARY UST CLOSURE El 7.USE PERMANENT SITE El 5.CHANGE OF INFORMATION <br /> CLOSURE ONS <br /> DATE liST PERD4ANENTLY CLOSED: 4�g ❑ 8.UST REMOVAL <br /> DATE <br /> I. FAEXISTING UST DISCOVERED: 4,3M /13 <br /> I C <br /> FACILY IDR(Agency Use Only) CILITY INFORMATION- - <br /> BUSINESS NAME(So as Facility Name _Doi B mes As <br /> 3. <br /> BUSINESS SITE ADDRESS 1o3. CTTY�ck <br /> I-}r�lvr�a.+� Rd Io4 <br /> v, <br /> TANK II. TANK DESCRIPTION LL <br /> / �( ti' r _ _ 433 TANK MANUFACTURER 433. " ..a <br /> TNCONFIGURATION:THIS TANK IS 434. <br /> ` 'l nl(�nemS 1.A STAND-ALONE TANK Complete one page kr h <br /> DATE UST SY 7EM INSTALLED 435. TANK CAPACITYINGALLONS 436. ❑ 2.ONE INA COMPARTMENTED UNIT .putn.t in rhe it <br /> Z�L+� IfC NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> III. TANK USE AND CONTENTS 17 <br /> TANK USE ❑ Ia.MOTOR VEHICLE FUELING ❑ Ib.MAREJA FUELING - <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE Ie.AVIATION FUELING 439. <br /> ___❑ 6.OTHERGENERATOR FUEL 0 95 UNKNOWN (Snclada Uud oil) ❑ S9 OTHER <br /> (Spe L), f, ORFO1L jBSC 425]g1,5(ac3]�a <br /> CONTENTS PETROLEUM: ❑ ]a.REGULAR UNLEADED iH'49 OTHER($ ify); <br /> ❑ 3.DIESEL ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMRIM UNLEADED 440. <br /> ❑3.IE7 FUEL A6.AVIATION GAS <br /> -. ❑ B.PETROLEUM BLEND FUEL 9.OTIIERPETROLEUM(Specify): IUQ(Jnl <br /> NON-PETROLEUM:❑ 7.USED OE, --- 440. <br /> ❑ 10.ETHANOL _--.-- <br /> ❑ IL OTHER NON-PETROLEUM(Specif,): 4406. <br /> IV. TANK STRUCTIO <br /> CO N <br /> TYPE OF TANK �._..._. - +�, <br /> PRIMARY CONTALNMENT �-l.SAIGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN <br /> �.STEEL [13.FIBERGLASS -- 443. <br /> ❑ 6.INTERNAL BLADDER .- -.-.._.-. <br /> ❑ 7.STEEL+INTERNAL LIIJMG 444. <br /> SECONDARY CONTAINMENT 1.STEEL ❑ 95.UNKNOWN ❑ 99.OTHER($Purfy); 444. <br /> ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90NONE _0 9S_UNKNOWN ❑99.OTHER_( ify): <br /> OVERFILL'PREVENTION ❑ 1.AUDIBLE$VISUAL ALARMS -r /BALL FLOAT <br /> 45. <br /> '-' " ❑ 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ q.TANTO MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFII,L PREVENTIONE UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION .SINGLE WALL Q-_2 DOUBLE WALL ❑ 99.OTHER___ <br /> 460. <br /> _[y`PRESSURE 0 2 GRAVITY 3_CONVENT[ONAL SUCTION ❑ 4 SAFESUCTION 2263 a )) <br /> 33CCR 3 458. <br /> PRIMARY CONTAINMENT ❑ 1.$TEFL ❑ 4.FIBERGLAS$ ❑ 8.FLEXIBLE ( <br /> ❑ 90 NONE ❑ 95 UNKNOWN 99.OTHERS ❑ IO.RIGID PLASTIC 464. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ( aeufi'): 464. <br /> ❑ 4.F®ERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 4646. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTF7ER(Specify): 464c <br /> PIPINGlFURBINE CONTAINMENT SUME TYPE ❑ l SINGLE WALL ❑ 2.DOUBLE WALL <br /> �` �V.r.` -' � _ _ -- ❑ 90 NONE - 464d. <br /> VI. ,VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ���.$-TE-FL (] 4,FR3ERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE <br /> 4644 <br /> VENT SECONDARY CONTAINMENT 1401.STEEL ❑ 99.OTHER(Specify): 464et. <br /> ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER S 4 <br /> VR PRIMARY CONTAINMENT ( P 'eel�)- 4641. <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC <br /> VR SECONDARY CONTAINMENT ❑ 90.NONH ❑ 99.O-I (Specify): 4�- <br /> ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify); K <br /> VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641` <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 464'. <br /> RISER SECONDARY CONTAINMENT -..-__---. ❑ 99.OTHER(Spaity):�4644 <br /> _ ❑ L STEEL ❑ 4.FrBERGLASS ❑ 10.RIGID PLASTIC_❑ 90.NONE ❑ 99.OTHER(Spxify): 964k <br /> FILL COMI'ONF,NTS INSTALLED ❑ 1 SPILL BUCKET 46411 <br /> ❑ 3.STRIKER PLATE/BOT70M PROTECTOR ❑ 4 CONTAINMENTSUMP 45la-a <br /> VII. UNDER DISPENS_ER CONTAINMENT(UDC) <br /> C70- <br /> -NS FRUCT_ION TY PE _ LJ 1 SINGLE WALL ❑ 2 D_OUHLE WALL <br /> CONSTRUCTION MATERIAL - -"- ❑ 3..O HER(S DISPENSERS __❑ 90._NO_NE 4694 <br /> ❑ I.STEEL ❑ q,FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(SpcmCl) 4696. <br /> VIIL CORROSION PROTECTION 4694 <br /> STEEL COMPONENT PROTECTION ❑ 25ACRIFIC[AL ANODES) ❑ 4.IMPRESSED CURRENT <br /> ❑ 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:Icertify tbut this UST system is compatible with [he harardous substance stored and that the information provided herein is true, <br /> accurate in full to p9wlth legal r wrements. <br /> APPLICANT SIGNATURE DATE _fI .L Ap/V 470. <br /> APPLICANT NAME(print) O� 471' APPLIC ITLE 472. <br /> ✓ieE Ayv ��- <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />