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UNIFIED PROGRAM CONSOLIDATED FORM Dl S L3 N <br /> UNDERGROUNDSTORAGETANK <br /> O PERATING PERMIT APPLICATION- TANK INFORMAI IO ••`�� <br /> 8 TYPE OF ACTION (Che mte item only. For a UST closure or removal,complete only this section and Sections 1.16 IIL!F,and l'below) 439. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST 'LOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE USTPERMANENT Y CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 43W- <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Us.Only) <br /> llESS NAME(Same a Facifit me or DEA-Doing Business As) 3. <br /> o e Na <br /> BUSINESS SADDRES lol. BU HNESS SITE <br /> •e- le J <br /> II. TANK DESCRIPTIO <br /> TANr _ /( 432. TANK MANUFACTURER /t 433 TANK CONFIGURATION:TI BS TANKIS 434. <br /> /I J� O v /' _ �q� ���•„Ie,gtS ❑ 1.ASTAND-ALONE TANK Co WWmW .n pYm4uch <br /> O (,E',5 ({'� /�a rI ll►r/'� <br /> X2.ONE M A WMPARTMEN TED UNIT rempmneat x icic <br /> DATE UST SYSTEM INST kLLED 435. TANK CAPACITY GALLONSD 436. NUMBER OFF C`OMPARTMEI ITS IN THE UNIT 432. <br /> III. TANK uSF AND CONTENTS <br /> TANKUSE Xie.MOT RVEHICLE FUELING [3 1b.MARINA FUELING ❑ Ic.AVIATION FUEWNO 439. <br /> CI 3.CHEM CAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(m*du ti ed 00) ❑ S.EMERGENCY GET IERATOR FUEL[HSC 1::8I.X4)e <br /> 6.OTfflll GENERATOR FUEL [195.UNKNOWN _______❑ 99.OTHER(SpecB3 <br /> CONTENTS PETROLEU �te.REGULAR UNLEADED ❑ Ic MIDORADE UNLEADED C3 1b.PREMIUM UNLE%DED 449. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL [16.AVIATION GAB <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM <br /> NON-PETRO.FUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11 OTHER NON-PETROLEUM(Sp city): 4u <br /> IV. TANK CONSTRUCTION <br /> t TYPE OF TANK n LSINGLE WALL 2.DWBLE WALL n 95.UNKNOWN 443. <br /> �!-_ _.-__ ____.._-__.._�+ _____ ----______ -___ ._. 444. <br /> PRIMARY CONTAINME ❑ 1.STEEL ryA3.FIBERGLASS ❑ 6.INTERNAL BLADDER <br /> ..7_STEEL+INTERIOAL LINING ❑ 95.UNKNOWN 4'1 <br /> __❑ 99_OMER(SP�); . <br /> _. <br /> SECONDARY CONTAIN NT ❑ I.STEEL .FIBERGLASS 13 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ___ 90.NONE .95.UNKNOWN ❑99-DR R Usp-COy: <br /> OVERFILLPREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS EI2.BALLFLOAT JC 3.PILL TUBE SHUT-OFF7 ALVE 452' <br /> ❑ 4 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMEN'.' - <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE WALL 2.DOUBLE WALL U99.OTHER ___ _ - ___.__-_ 960'_ <br /> SYSTEM TYPE____, PRESSURE _M 2_GRAVITY ❑ i.CONVENTIONAL SUCTION ❑4.SAFE SUM ION[23 CCR 12636(eX1)1 _4...:... <br /> PRIMARY CONTAINMEN ❑ 1.STEEL '4.FIBERGLASS C3S.FLEXIBLE ❑ I0.RIGIDPL.$TIC 464. <br /> _ [190.NONE -95.UNKNOWN [199.OTHER(S e�iif 964 <br /> SECONDARY CONTAIN NT [I I.STEEL 4.FIBERGLASS [3 B.FLEXIBLE El 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S ems*): <br /> _....___.__-___...._.._...._._ __. __.___.. .__ 4640. <br /> PIPING(TURBINE CONTA NMENT SUMP TYPE IX 1 SINGLE WALL 2.DOUBLE WALL Q 90.NONE - <br /> VI. VENT,I APOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY_CONTA__ MENT 131.STEEL_A4_FIBERGLASS [310.RIGID PLASTIC [39o.NONE [3EN99.OTHE R(Specify): - <br /> VTSECONDARYCO AINMENT O_1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC �90_NONE ❑ 99.OTHE it(Specify): 4640._ <br /> VRIMARY CONTAIN NT ❑ 1.STEEL_. 9 4.FIBERGLASS [3, ❑_10.RIGID PLASTIC 90.NONE [199.OTHE R(Specify): <br /> R P7* <br /> 4 64A. <br /> VR SECONDARY CONTA [3MENT 1 STEEL ❑ 4.FIBERGLASS [3 10.RIGID PLASTIC *90.NONE ❑ 99_OTHE R(SpecJy): 4NhL <br /> .._ _T_.- 1, <br /> _VENT PIPINGTRANSITI 4 SUMP TYPE 1.SINGLE WALL CI 2.DOUBLE WALL- 90.NONE __ _ ,_ _ 4M, <br /> RISER IM <br /> PRARY CONTA ENT1.57EEL ❑4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHE R(Sper4ry): 464n, <br /> RISER SECONDARY CON AINMENT ❑ 1.STEEL [34.FIBERGLASS ❑ S29 <br /> 10.RIGID PLASTIC 0.NONE E] 99.OTHE K(Sparify): 464x1. <br /> _ 4a <br /> FILL COMPONENTS INS LED LSPILL BUCKET 3.STRIKER PLATE/BO'ITOM PROTECTOR 4.COMt.INMENT SUMP _ <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ___________ I.SINGLE WALL 2.DOUBLE WALL 1''1 3.NO DISPENSERS ❑ 90.NONE 469e <br /> _.__-_.__._._-_..__.�1_______......___-trL_____-....._ <br /> CONSTRUCTION MATER I.STEEL ❑ 4.FIREROLASS 10.RIGID PLASTIC ❑ 99.OTHER(Spxify) 469c. <br /> VIII. CORROSION PROTECTION <br /> $TEFL COMPONENTP 'ECTION 02.SACRIFlCW.ANOD 4.IMPRESSED CURRENT 6.ISOLA'-"ION - <br /> 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 to y that this UST system is tum etlble with the hazordo4u eubataaee stored and Hat Lrm'don provided hereh a true, <br /> aecur a and m Ila al r uirements.APPLICANTSIGNATURE DATE / <br /> 4n. <br /> APPLICANT NAME(print) APPLICANT TITLE <br /> Efl'naiv� 1 I/17/08 <br /> UPCF UST•B Rev.(12/2W -1/2 www.unMa. <br /> ouorg ( <br /> I <br />