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UNIIFIED PROGRAM CONSOLIDATED FORM �/y L6 UNDERGROUND STORAGE TANK t OPERATING PERMIT APPLICATION-TANK INFRMATION Pnr I'm o�efxhe)av "" TYPEOFACTION IC'Ase*.ir. .ry- YOra[/Sl vlosur.VTo�mvL MASolefe OrliJ'+)'" m mei 0=IIANOE OF II4FORMATION j!I.NEWPERMI'I' ❑ 3.RENEWAL PERMIT 8.1)SI'REMOVAI. 6.TEhD'ORARY USI CLOSURE 7.UST YERMANENI'CLOSURE ON SM a3ort DATE USI pERMANEN'PLY CLOSED' 43a. ATE EXISTWG UST DiSCOVERPA' I, FACILITY INFORMATION FACILITY ID 0 U8e"CY Ua 014) BUS NESS NAME(S.n -F-UYNams or DBA-D"'9'ftiurssAa) JaC c Cv �,,.... CITY t ,m. BUS S 311'L'ADDRESS Tm. ). . ��: II. TANK DESCRIVn0N la. TANKIDO au TANKMANMACIURER 45- TAT4KCONFIGIIRATION:TIiISTANKIS j1�spS161�) 01.ASTAND-ALONE TANK C�f�.ws�Iw� 2.ONEINA COMPAR7MENIED UNIT �"wl�um6ewn 7. DATE USI SYSTEM IN 435. TANK ACITY IN GALLONS 43[ NUMBER OF COMPARTMENTS M I.UNIT RIC '� D III. TANK USE AND CONTENTS <W TANK-USE C1Is.MOTORVEIBCLEFUFI.ING p III MARINAFDELIM p IU AVIATION Elml.ING El 3.CHMAGCAL PRODUCT STORAGE p 4.HAZAR000SWASTENdv T ou 0 5.04 RaEK YG 1ATOR FUEL, 15C PJ3Zi13(c)� __p Aml�RarayP�ewmRFlnR. _. . 0"-UNKNOWN _--- \ r..nFn ❑ 10.PRE16MMUNLEADED sY' (,yN7Eni'Is PETROLEUM... O L.RI'liUlaR UNLFAD® p 5 MIDchATx1O p 6.AVIATION GAS Q 3.DIESEL ❑ Ya ❑ LPEMOIEUMBLENOFUEL p 9.OTHERPEIROLEUM NOM-PE[ROLF]1M:Q 7.USED OLL l0.EfNANDL ILOTHERNON•PEIROLEUM ftCAt, 6 W "&; O IV. TANK CONSTRUCTION .D TYPE OF TANK 1.SDTGLE WALL p 3.DOUBLE WALL ❑gS.uNIINUwN --�---- ERG Ss6. PRIMARY CONTAINt.1Eft•7I I.SIFFEi. Q 3.NI �- p 95.INTERNAL MADDER 7.STEFi..1N1'F]tNAL LINR4G Q 6.EMEROWN ❑ 99.OTF67tl5L°u 7. IXE'�D Y5. SECONDARY CONTADiME U ❑ I.STEM- ❑3.mtimt Ass ❑6.Ex7POi10R MFMBgANGLulPx�OS`�✓,,`(y} ❑ 90.NONEQ 9S.UNIWOWN ja99.OTHER("PT�6- \`44JJ ..... . OVERFILL PREVENTION p 1.AUDI EAYISUALAme �p 2 FROM OVERFILL 3PREVENTION UB'A4N1' [14-7ANKMFEISomm V. PRODUCT/WASTE PIPING CONSTRUCTION P>PlrccoNSTRVCTTtnv ❑ 1.sINGLEwAu Q znGDBlEwua p 99.OTHER SYSTEM TYPE __❑ I.PRFssURE ❑ 2GRAVffY p 3.CONVENTIONAL SUCDON ❑ 4 SAFE SUc 10-12 LxP-63k_y9L-.--'- PRIMARYCONTAD4MENT p I.STEEL ❑4.F®FRGLASS ❑B.FLE%IBLE ❑ 10.RIOID PLASflC 44+a ❑90.NtR4E p 99.IBd10TGWN ❑99.dDBTR(SPmN)_ 10.main PLASI3C wG 90.NONE SECONpARY CONTAWMENT p t.sTOP.I. ❑4.FmERGLAss ❑ atTfwBLe p asvc p 90.NONE ❑9s.u14KNowN ❑97.OTHER -Ty>: ---� P[PD4GfIT1RBINE CONTAINMENT'SUMP TYPE I.SINGLE WALL 2.IXRIRLE WA., ❑ VL VENT,VAPOR RECOVERY(VR)AND RISER/FILI.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAI4ME347' ❑ I.S'IFF3]• Q 4.FIBERGLASS ❑ 10.IBOmPLAP.TIC (tT gO.NONE ❑ 99.OTIBiR(SPedTj VENT SECONDARYCONTAINMENT ❑ I.STEEEL p 4.FIBERGLASS p IO.RIGED PLASTIC a9O.NON6 p 99.ORHER(SP®y): wn. Dv1ARYCONTAIIh4ENT p I.DIHBt• ❑4.FIBERGLASS lo.wam PLasrlc Q9O.NONE 11 99.ITLHER(SpmIM VRPRsu.. _..... VR SECONDARYCONTAWMEPII p t.57EH. p-4.F63ERO[.AES_p IO.RIOmPLASGC ®9o.NONE Q 99.m'HFR(sPF�A'): 4�1. VENT PMO TRANsrrlGNSUMP IVPE ❑ 1.sux1LEWALL D 2.Da16LEwau. la-90.1,10NE RISER pRMay CONTAINMENT 0 LMIEL Q 134.FIBFRGI-ISS 1O.RIGHT PLASTIC 9o.xoNe ❑99.17TIEa(sP=w&): INw . RISER SECONDARY CONTAINMENT U 1.57EEI. p 4.FRBAI7LAS5 Q Io.RIGiDPL u ILL 90.NONE ❑99.oTTSR(spmy): 45Y FILL COMPONENTS INSTALLED 1.SPILL ❑ 3. OTTOM PROTECTOR Q 4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT(UDC) .Y. CONSTRUCTION TYPE O 1.sBVGLE WALL ❑1.1X1UBLEwAL. ❑ 3.NO DL9PHSERS ❑90.NONE - -157 CONSTRUCTION MATERIAL ❑ 1.S7EFT. ❑4_FIBERGLASS p 10.WGIDPLASTIC Q 99-OTUERISPmcifF) VIII. CORROSION PROTECTION «t: STEEL COMPONENT PROTECTION ❑ zsACIUFlc7AL nxoD S ❑ 4.IMPREssFn CORREFrr 6.IsounoN IX APPLICANT SIGNATURE CERTIFICATION: I Mrdfy that the USI system is t:001pstib)e with the ha mi)w SUBSdUCs stossd sad Mt the iefOt amRtbu psoridel herdR is true. O[[Ol9TP,and M foU With PeFn m i, aro. APPLICANT SIGNATURE DATE is � alz. J 411' I APPLICANT TITLE P-0 4,- APPLICANT NAME(prim) UPCF UST-H Rev.(12aOO7)-12 www.ueldo[sOTg S 'd 90SISES602 2ILij eZb :60 01 b0 ReW