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P. 10 <br /> MAY,-31-2010 11 :24 AM - <br /> mope 1 w <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION One fwm usT) <br /> TYPE OF ACTION (Check one item enty. For an UST permanent closure Or removal,complete only(his section and Sections I,Il,[it.IV,end IX below) ��° <br /> 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.USTPERMANEN'I'CLOSURESITE 8.USTREMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4J01 DATE.ON EXISTING UST DISCOVFRFD; <br /> L FACILITY INFORMATION <br /> FACILITY ID q(Agerocy Use Only) - - <br /> BUSINESS NAME(Same as FACILITY NAME!VADoiBaAricssA ) <br /> J- en /n <br /> • <br /> DU TWISLADD)IHL er Slaer•a. ,1W Iv ('f1Y� <br /> ((�E X11.TANK DESCRIPTION <br /> TANK IDN 451 TANK1/ryMANUFACTURF.R 4'1 -ANk(ONPIOURAT,014 THISTANXIS 414 <br /> Av23�Sv `�� K2ONE NACOMPARrmVNTFDI,Nrf. <br /> rom r4a aa. . ...Mat la 0s mir <br /> DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN OALI.ONS '116 NIIMBFR OF COMPAR'IMENIS IN THE UNIT 411 <br /> t <br /> IIL TANK USE AND CONTENTS <br /> TANK USE Is.MOTOR VEHICLE FUELING ❑ Ih.MARINAFUELING ❑ N.AVIA nON FUELING 479 <br /> 1.CHEMICAL MIODUCT STORAOE ❑ 4.HAZAR000S W AS'1'Rll c.1, el V W t 1I . C3 s r;MPROP.NCY OENERATOR FUEL pIsc imai N.)I <br /> IJ 6.ATHER GENERATOR FUELO 95.UNKNOWN 1399.0'rHER I ): 4394 <br /> CONTEN'r5 PETROLEUM: 13 la.REOUL,AR UN(.FAnFD LJ la MIDORAIM.UNLEADED © Ib.PREMIUM UNLEADED 440 <br /> i.OIESRL ❑ S.JETFUFI. ❑ 6,AVIATION OAS <br /> S.PETROLEUM n1.PNn rum. o.OTHER PE'T'ROLEUM S u ; NQs <br /> NON-PETROLEUM:Q L USEUOIL In,F.THAND,. <br /> OTII,R NON-PETROLEUMS i : 410p <br /> IV. TANK CONSTRUCTION <br /> TVPR.OF TANK 1,SINGLE WALL2.DOUBLE WALL E3 15.UNKNOWN N7 <br /> PRIMARY CONTAINivmN'I U 1.5 3.FIBERGLASS ❑ 6.WTERNAL BLADDER 444 <br /> ❑ 7.S RAL .ININ(1 ❑ 93.UNKNOWN ❑ 1Y1.OTHER IS i 4444 <br /> SECONDARY CONTAINMENT ❑ L S'rEEL 1,PInnROLAR6 ❑ b.EXTERIOR MEMBRANF.LINER ❑ 7.JACKETED u5 <br /> 90.NONE 91,UNKNOWN t-I 99.OI'HRR ISPeaif 645' <br /> OVERFILL PREVENTION LAUMBLFR VB1IALn�LARMs 112.HALL F'LUA'f a,FILLTUBESHUT•OFFVALVE 412. <br /> ❑ 4.TANK MEETS REOUIRP.M(IN'rS POR EXEMPTION FROM OVrRFI L I'kEVENTIUN EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPINOCONST'RUCTION In I.SINGLE-WAI.I.17.132.DOIIBLL-WALLED 'M.01'MER 'W <br /> SYSTEM TYPE I.PRESSURE ...DIM'I'TY ❑ J.CONVEN'r10NAL SUCTION Lj 4.SAFE SUCTION 21 CCR F2636(w)]1 416 <br /> PRIMARY CONTAINMENT U I.STEEL 4.FI n,ROLASS ❑ 8.FLL:XIHLN ❑ I0.RIGID PLARTIC a6.5 <br /> 90.NON, 9S.UNKNOWN (] 99.U'FHERIS airy): 464e <br /> SECONDARY CONTAINMENT 1.STEEL 4.FInEROLASS ❑ 8.PLL'XIHLF. ❑ 10.RIGID PLASTIC 46N <br /> ❑ 9q NONE ')5.UNKNOWN 13 W.01'HRR(S mN); 466c <br /> PIPIN(Vn1RBINa CON'rAINMENT SIIMP'IYpE 1111 4717 l,E wnLL 0 2.L)UUBLIi WALL ❑ 90.NONE <br /> V6 VENT,VAPOR RECOVERY(V R)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 1,$TP.Et. 4 YIHERGLASS I0.RIOIO PLASTIC W.NON, W.OTHER(SpxiW) 46w <br /> (6441 <br /> VENT SECONDARY CONTAINMPNT ISMR. 4,FIBERGLASS IfI.RI(llD PL.AR'1'I(' 90.NUNE 99.OTHER(Spmiry) P <br /> 61PI <br /> VR PR MARY CONTAINMENT I.STEM. X 4 FIIJIAOI,ASS I0.RIGID PLAS'IT 90.NONE. 0 99.0114ER(Specify) 'I is <br /> t64 I <br /> Vk SECONDARY CONTAINMENT L3 1,STEEL W4.FIBERGLASS ❑ lo.RIGID PLASTIC 0 90.NONE 0 7-OTHER(Specify) 46dh <br /> deMl <br /> VENT PIPING TRANSITION SUNIP TYPE _ ISINULEWALL_ '-^-Cl2 nt1UDT.,WALL 70.NONE 46a. <br /> RISER PRIMARY CONTAINMENT LS4FIBERGI.ASS III.RIGIOPLASTIC 90NONE "ADTHFR(Spmily) 461i <br /> RISER SFCONnARY CON'i'AINME.14 I' I.STEEL. _ 4.FIOFRtlLA%S O.RIGID PLASTIC 90,HONG 99.OTHER(Spwify) <br /> MCI <br /> FIL1.COMP(INPN'I$INSTALLED _ 1.SP(Li.nlltxL•"1' i. WkI <br /> STRIKER PLA'rf-410'ITOM Pk0'1'RCTOR 4.CONTAINMENT SUMP 451..: <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> L'ONSTRIJC'i'ION'fYPE I,SINGLE WALL Q 2.OG1.RI.P.WALL ❑ :3,NO DISPENSERS ❑ 90.NONE 46% <br /> CONSTRUCTION MATERIAL .STSEL Ij 4.FIF.ImULASS &&10.RIOT.PLASTIC U WI.UTOLK fS ei ) 469bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONIiNT PROTECTION ❑ 2.SACRIFICIAL ANnDG(s) U 4 lMPRES.SRDCURRT:N'I' ❑ 6.ISOLATION 44k. <br /> IX. APPLICANT SIGNATURE <br /> CERT1F11CATION: I eertlty that this LIST System is compNtble with the hsnrdous substance stored and that the Information provided herein Is true,Accurate, <br /> And is full compliance with lel MU -� ---__ <br /> 4rD <br /> APPLICANT'SICNATURF DAR• „�Cy /v <br /> APPLICANT NAME(print 4r I' 1PI'LIC.(NT"ITTLE { l J � 4n. <br /> ]UPC It UST-R.In. a300� <br />