BILLING - Laserfiche WebLink

Home Browse Search

RECEIVE UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MAR 0 3 2016 OPERATING PERMIT APPLICATION-TANK INFORMATION(One A YPE OF ACTION (Check one item only. For-,UST permanent closure or removal,complete only this section and Sections I,%]B,IV C'l� 1,NEW PERMIT 0 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFO RMATIONFjLI)'�"1.1 nFpaRTA T ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED X /1 430a DATE EXISTING UST DISCOVERED '�� 1 430b 1110 _... .. , ... ..;...... FACILITY ID#(Agency Use Only) _ BUSINESS NAME((Sallie as FACILITY NAME orDBA-Doing Business As) ` � 3 Buds SITE ADDRESS r o CID, s TANK ID# �� 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 >A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. DATE USTSYSTEMINSTALLED 4MUJ Cnm leaane paxefor each coca 4ncnl in lhc ,j; TANK C IN GALLONS 436 NUMBER OF COMP,ARiMBNTS IN THE UNIT 437 TANK USE ❑ Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA PURLING ❑ Ic.AVIATION FUELING .... 439 ❑3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inclulaa Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HEC 4252aL5(c)] ❑ 6.OTHER GENERATOR FU EL 95.UNKNOWN ❑ 99,OTHER.(Speclfy): 439. CONTENTS PETROLEUM: ❑ Ie.REGULARUNLEADED 1] Ie.MIDGRADEUNLEADED ❑ It.PREMIUM UNLEADED 440 p ❑ 3.DIESEL El5.JET FUEL El6.AVIATION GAS GV ❑ S.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM (Specify), 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL F Ela a OTHER NON PETROLEUM S ecr 440b PEO TANK .w :tet r r ?,c 'Ic: 4 , IV TANKG62IlCTON LSMGLH WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN r. - �- -"' PRIMARY CONTAINMENT ].STEEL 443 ❑ 3.FIBERGLASS ❑ 6.INTERNAL HLADDHA qqq ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): '444. SECONDARY CONTAINMENT ❑ (.STEEL ❑3.FIBERGLASS ❑ 6.fiXTEA]OR MEMHRANHLINER ❑ 7.JACKETED 443 90.NONE ❑ 95.UNKNOWN Q 99.OTHER(Specify:. 445a OVERFILL PREVENTION ❑ 1.AUDIHLH&VISUAL ALARMS ❑ 2BALL FLOAT ❑ 3 FILL TUBE SHUT OFP VALVH 452. ❑ 4 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERPILL PRHVENTION EQUIPMENT /✓,�Qd]1� .. f Ax � x .............. -----R0 � �,), z1STEPI�'rT�V�yCONS'IPRU.e,��9�t, .. .. PIPING CONSTRUCTION00f-SINGLE-WAtLED ❑2.DOUBLE WALLED ❑99.OTHER � - SYSTEMTYPE 6(ir 458 ❑ 1.PRESSURE ❑ 2.GRAVITY ..pC3.CONVENTIONAL SUCTTON ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEMBLE ❑ 10.RIGH)PLASTIC 464 11.90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ I.STEEL, ❑ 4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10.MUIDPLASTIC 4646 ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99 OTHER(Specify): '"V 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL ❑ 2 DOUBLB WALL ❑ 90 NONE stf 464d ^ E` I ,V,4° ORR�Cb7,'x'( I2)ANI)r,2ISER/FILLEII'Ir�);RT1N'G CO�' {`RUC'FION-.. . ._ VENT PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4,FIBERGLASS ❑ 10.RIGID PLASTIC O.NONE 0 99.OTHER(Specify) /�4f464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ,4 464e1 ❑ d.FIBERGLASS ❑ IO.RIGID PLASTIC O.NONE ❑ 99.OTHER(Specity) /ildej& 4666nf VR PRIMARY CONTAINMENT ❑ LSTEEL ❑ 4.FIBERGLASS ❑ IO.RIGID PLASTIC O.NONE ❑ 99.OTHER(Specify) 4641 VR SECONDARY CONTAINMENT �l✓L 4641 ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC r.F'J20,NONE LJ 99.OTHER(Specify) f t 464h VENTPIPING TRANSITIONSUMP TYPE ❑ 1.SINGLE WALL Cry Qi(� 464h1 ❑ 2.DOUBLE WALL '.NONE RISER PRIMARY CONTAINMENT ❑ 1.STHEL ❑ q,FIBERGLASS r�� ..,/C 4641. ❑ IO.RIGID PLASTIC .6d-90.NONE ❑ 99.01HEK(Spewy) 464j RISER SECONDARY CONTAINMENT ❑ LSTEEL QaP 4641 ❑ 4.FIBERGLASS ❑ IO.RIGID PLASTIC d[,a]'➢p,NONE ❑ 99.OTHER(Specify) ,,,g 464k FILL COMPONENTS INSTALLED LSPILLBUCKET .64/�iVLs' 4Mal ., ❑ ❑ 3 STRIKER PLATFIBOTTOM PROTFCTOR ❑ q CONTAINMENT SUMP 451 a-c ...u."�?:r`wa�a.,.�n"��M., CONSTRUCTION TYPE .•"•- .. ❑ I.SWGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 0.NONE J(Jf�('d 469a CONSTRUCTION MATERIAL ❑ (.STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTM ❑ 99 OTHER(Specify) � 469bc STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANOD S 1 PR A+1 _. " .. .. EC) ❑ 4.IMPRESSED CURRENT ❑ 6 ISOLATION e f J,„,� ��, 448. a7Ar CERTIFICATION I certify that this UST system is compatible with the haz and in full Iiance With le of requirements. substance stored and that the information provided herein Is true,accurate, com APPLICANT SIGNATURE DATE 470, APPLICANT NAME APPLICANT TITLE 4n J��✓t S �6rJ UPCF UST-B-1/2 Rev.(12/2007)