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• <br /> UNIFIED PROGRAM CONSOLIDATED FORM �( 4 <br /> UNDERGROUND STORAGE TANK the form off USI) <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION c 4.�L. <br /> irem FnrG FIST C7o3llrr ar rrmwaT,template oMy rMs.werJnrt atd SeaRmt4l,U 111, and u Wiwj <br /> TYPE OF ACTION (ClaaaX oaa m'1' 3.RENEWAL PERMIT ❑ 5.CHANGE OF 1NPORMATIt1N <br /> - <br /> NEWPERMIT T VST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> 6.TEMPORARY UST CLOSURE 4 <br /> ♦3A. DATE I7OSTING UST DISCOVERGO" <br /> DATE LISP PEItMANENT(.YY CLOSED' ' <br /> L FACILITY INFORMATION 1. <br /> FACILITY ID$ um Only') - - 3. <br /> BUSINESS NAME(Smarm FacflXyNamforDB.M-DdnR BmlrrcrAsf <br /> N. CITY <br /> BUSIN S SITE ADDRESS �r <br /> IL TANK DESCRIPTION . <br /> 831. TANK MANUFACITIRER m. TATIKCTAND-A RA770N:T'HISTANKIS <br /> TANK mR �, (�/ ASTANA COW TANK Comprirmr Per Torruh <br /> 1 F42-ONE INA COMPARTMENIPD IRRT °ora•^�^mrintbwn. <br /> DATE UST SYSTEM IN ALL +35. TANK CAPACITY IN GALLONS <br /> a36. NU113DER OF COMPARTMENTS IN THE UNIT a7. <br /> III. TANK USE AND CONTENTS <br /> Ib.NAMNAFUFLTKO u 1,MIATIONFUELING <br /> TANK USE p I. HEMICAOBoDuCTSTORELING p m,n WASTEDNtuts WdO.T) ❑ 3.PMEROENCYGET�tATORPUE�I�!'i'�r.�(cR <br /> ❑ 9.CNL/dICAL 1'R03ABCT STORAGE ❑ 7.fIA2AR (SPr�+h)' LU.3 _�1 �` <br /> _ ❑ 6.UDBR O@iPRATT1R FUd O93.UNKNOWN _ un. <br /> CONTENTS ]2TROlEIIM: O ia.REMA-KRUNLPAOEO ❑ laf 'R+ ADEUNLFl1DED ❑ Ib.PREMIUld UNLEAD <br /> 0 3.DIESEL- p 3_SEFFUEL ❑ 6.wv1ATlON OAS <br /> Q e.PETROI.EUMBLEKR)KIEL E 9.mllmprmol EIIM_�_ hY .....- .. <br /> -- _--NO -PEOLE.UM7. ts®OR 0 10. <br /> CUL <br /> I I.Oit1ER NON-PEIROLEl1M <br /> IV. TANK CONSTRUCTION 44, <br /> TYPEOFTANK _�_.1.SINGLE WALL-0 I DW)BLE WALL ❑ 95, <br /> PRIMARY CONTAINMENT LAI.STEEL O 3.F®IDtUt.ASs ❑95(TNNIt BT'`��13 .O71MR(SPrcTj•). mr <br /> MOWN <br /> p 7.57EFI.t ITPRNNAL LTMNG p 1 � p�.JACKE� <br /> 3ECONDARYCONTARNIv1ENT 0 90.1103. C3 FIBERGLASS �6_F7CTFRIOR aun <br /> 0,90.NONE 093.VNIDNOWN99_(TDRER <br /> _OVERFB.I.PREVEIMON O LAUDBLE RVISUALALARMS OZBAILFTDAT O3.FILL Ti16ESHlIf-OFF VALVE <br /> iaz <br /> CI <br /> 4.TANK MFEIS FOR E7EMFf10N FROM OVERFILL PREVIDMON <br /> EOUDWENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PWMGCONSTRUCTTON ❑ 1,sONOLe wALL p 2.DOUBLEWALL ❑ 99.ODER <br /> SYSTEMTYPE I.PRESSURE ❑ 2.GRAVTIY ❑s.CANVENILONALSIICDON ❑a.SAFESIICRGN I9 CCR EtA <br /> PRIMARY CONI•AINMENT 0 L srE77. 4.FIBERGLASS p 8.FLEMBLE U 10.RIGID PIANITC <br /> p 9D.NONE_ p 95AINKNOWN 0 99.OTHER(Spedtyk4fiK <br /> aUb <br /> SECONDARY CONTAINMH97' p I.STEEL ❑4.FBHRGLASs ❑9.FLEIGBLe Oto.RIOt0 rl.Asnc 43a� <br /> [390.NONE p 93.17NKNOWN ❑ 99.UDIOt(sped ): 13 9D 4"a <br /> PIPINOTEJR INE CONTAIINMQ'IT suMP TYPE 1.SINGLE w <br /> VL VENT,VAPOR RECOVERY(VR)AND <br /> RISER//FILL PIPE PIPING CONSTRUCTION <br /> 461n <br /> VENT PRIMARY CONTAINMENT ULSTEE7. 04.FlBFRGLASS ❑ 10.RIGIDri.AST1C Q1,90.NONE 099.UIILF3t(SpuihY <br /> VENT SECONDARY CONTAINMENT 0 i.STEEL 134.FBEROLASS 0 to-RIGH)PLASHC (190.NONE p 99.01KBR(Spedh): awn. <br /> yR PRIMARYCONTAINAE:TiT ❑ LS1TE•L p AXIBERGLASS ❑ Io.RmPLASDC (i2_ 9o.NONE ❑99.OTHER(Sped(y): <br /> Aesn. <br /> vR SI CONI)ARYCONIAIINMENT I] 1.STM 0 4.FIBERGLASS 0 10,RIGIDPLAsnc W9D.NONE t1 99.pTTffR(Spadh): a L <br /> --__. <br /> ---' <br /> VENT p1pQNO YRAN$RION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2DOUBLE WALF. .city): __-..... <br /> RISER pRU1ARY CONTA@IMENT p LsTEEL 0 4.FIBEROLASS 0 10.R1GMFLASnf Ig'JJO.NONE ❑99.OHaFBR(SLR9i$): <br /> RISER SECONDARYCONIADNMEN'I 0 1.S71:EL ❑a.FIBERGLASS 0 10.RIGID PLAs73c ('d'4D.NGNE ❑ 97.OTIBR(SPrd[yY ol�sc` <br /> FILL COMPONENTS INSTALLED I.SPO.L BUCKET p 3.sTR1KER PLATFIBOIII'OM PROTECTOR ❑ 4.CONTAINMI+N1'SI1MP <br /> VII. UNDER DISPENSER CONTAINMENT NONE 469& <br /> CONSITRUCTfON TYPE _ 01.SINGLE WALL 02.DOUBLEWAI1 ❑3-NO DISPENSERS _.[7_ <br /> CONSTRUCTION MATERIA. 0 1.STEM ❑ 4.FIBERGLASS p IO.RIGIDPLASnC p 99.UITBR(SPKiy) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENCTI <br /> T PROTEON 2.SACRIFICIAL ANO S p IMPRESSED PRESSED CIBIRRFNT ❑ 6.LSOLATLON <br /> IX. APPLICANT SIGNATURE <br /> CE CAT[ I mtil9 that this USI SyRM Is CDmpdbk with EDC Itamrd0us cubdaart storeA eR0 that the aformali;a Provided hereiu Is true, <br /> aocara <br /> an (3BR1 mwith1 1 11 VL 470 <br /> APPLICANT SIGNATURE : DATE H <br /> an. <br /> 1 <br /> APPLICANT NAME(prim) ��` 1 ti \u an. APPLIC TI <br /> UPCF UST-B Rev.(12/21ffn-E2 www.RDldocaotx <br /> b 'd 90STSZ860Z 2l e.lo LTi, :60 01 b0 Pew <br />