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• 4 <br /> MAY-19-21109 11:54AM FROM-TRANS SYSTEM 509 625 3967 T-065 P.001/001 F-635 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROIINDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (GncfaDnperLIM u <br /> TYPE ACTION (Check one ilCnl only. For an UST pemusneat closure or�emovnl,Complete only ibis uccion and Sections L 11,111,]V,wd lX Below) <br /> ❑ 1.N W PERMIT ® 3,RENEWAL PERMIT M 5.CHANGE OF INFORMATION <br /> ❑ <br /> 6.1 -MPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SrVE ❑ S.UST REMOVAL JV n <br /> DATE ST PERMANENTLY CLOSED: <br /> a1-- I DATE EXISTING UST OISCOVERL;O: <br /> T. FACILITY INFORMATION <br /> FACILI V IDW(Agaac'y_U1104) ' <br /> l <br /> BUS ESSNATSITRANS SYSYNMEINCAD--gB-6l-Lis As) <br /> IPP CITY FRENCH CAMP I'H <br /> BUSINESS ssITEADDRFss 707 E ROTH RD <br /> IL TANK DESCRIPTION <br /> JJ'- TANK MANUFACTURER qJ TANK CONFIGUIIATIUNI THIS TANK IS J1J <br /> TANK Da E]1.n STAND-MANR TANK <br /> NEF-S 0 2.ONE IN A COMPARTMENTED UNIT. <br /> Gm Ineom ere'..h w• mmme veil. JJT <br /> DATE I STSYSTEM NSTALLED a35 TANKCAPnCITY IN GALLONS JJ6 NUMBER.F COMPARTMENT'S IN THE UNIT <br /> 12,000 GAL owt <br /> M.TANK USE AND CONTENTS <br /> TANK USE j'Ic.muTOR VEI IICTf FUELING Q It.MARINA FUELING El Is.AVIATION FUELINGJnr <br /> ❑ i.CHEMICAL PRUJL CTSTORAGE Q 4.HA7AR000SWASTEII Ieenth14( 19 ❑ 5.EMF,RGENL'YGENERATORFUL'LIliSC4cscNL3IgI uva <br /> ❑ h.UTHFR GENERATOR FV£L ❑ 95.VNKNOWN ❑ 99.UTHEII(S cify): <br /> CONTENTS PETROLEUM: ❑ I.DIESEL VNLEADLO ff IST FUKADP.IML[ADEU [1 lb.PRATI N LR4LCADEU <br /> n <br /> .1.UIESEI. ❑ S.JET FUEL ❑ fi.AVIATION GAS Jab+ <br /> ❑ I,PETKOLEUM nLFND PULL ❑ 9.OTIMR PE MOLEUM IS ecitvl: <br /> NDN-PETROLEUM:❑ 7.USED OIL Q III.ETHANOL <br /> II.OTHER N0N.PM1wLEUM IS If 1: Jwe <br /> IV. TANK CONSTRUCTION <br /> ua <br /> PH FTANK ❑ I.SR4GLf WALL '_.DOl1BLE WALL ❑ 94.UNKNOWN J•H <br /> PRIMA YC0N'1'AMMF.Ni ❑ I.51 EEL [a 3.FRIEROLASS Q 6.INTERNAL HLADDEIt JJy <br /> 7.STEEL+INTEIWAL UNMG ❑ 95.UNKNOWN ❑ Y9.OT14GR IS cEf 1: aa. <br /> SECONDnRY CONTnMMLNT ❑ I.STEER. U3,Fld£AGLAS-S ❑ 6.TXTERIGR MEMBRANE LINER ❑ 7„JACKETED 1151 <br /> Q 90.NONE ❑ 9S,UNKNUWN EIW.OTWlt(S dfvl` <br /> -dVBF LL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT a J.FILL TUBE,$1 IUT-UFF VALVE n' <br /> Q.4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION RQUII'.M ENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> LSINGLE-WALLED �^-.DOUBLE-WALLED ❑99.OTI4ER JW <br /> -IPM CONSTRUCTIIJN Jsx <br /> SY TYPE 1.PRESSURE ❑1.GItAYffY ❑ .1.CONVENTIONAL SUCTION ❑ J.SAFE SUCTION mCC0.41s?N+KI)I <br /> M <br /> PF[M--A RYCONTAR4MEN'I' Q 4.FIBERGLASS ❑ B.PLIXIBLE Q 10.RIGIU PLASTIC u.I. <br /> ❑ 9a.NONE ❑ 95.UNKNOWN ❑ 99.0THER(Sped141' JCJF <br /> SEGO)On2v CONTaMMEN1' ❑ 1.STEEL 4.nd[rtGLASS 6.FLEXIeiE ❑ ID.RJGJD PLASnc AN, <br /> ❑ 90.NUNS ❑ 95.IMKNOWN ❑99.U'1'HER ISPedfY): awd <br /> P[PIN URBINE CUN'fAINM[NT SUMP TYPE Q LSMGLE WALL �-ODUtl1.E WN.L ❑ 90.NONE <br /> VI.V ENT,VAPOR RECOVERY(VR)AND RISER/FILI.PIPE PD'ING CONSTRUCTION Jwa <br /> VENT R1MnRY roNI'AINMFNT LSTEEL 4.FIBERGLASS Q Io.IUGID PLASTIC 90,NONE 99.UTHPR(Sp=dry) Jwel <br /> ❑ 90NONE ❑ 99UTHER(Spccify) <br /> VENT arar <br /> of A <br /> ac <br /> VRP MARY CUNI'AINMENT L57P2L a,ndEitGLASS 10.RIGID PLnSTiL' ❑ 90.NONE 99.OTIIFR(Specify) JM <br /> Mh <br /> VRS• NOARY CONinWMEN7 ❑ LSTEEL Q 4.FIBRROLA55 Q 10.RIGID PLnSTJC 90.NONG ❑ 99.D't ER(Specify) udhl <br /> 2.❑OIJDLE WALL 90.NUNE -1M, <br /> VENT PIPING TRANSITION SUMPTVPE I. INGLE WAIL JwI <br /> RISER PRIMARY CUNTAINMEN'I' ❑ I.STEEL ❑ J.FId ERGIASS IO�RIGID PLASfC ❑ 90.NUNE ❑ 99.fTfNL'R ISPcaily) JM'I <br /> 01k <br /> RISER SECONDARY CONTAINMENT L STEEL 4.FIdEI(GLASS 10.RIGID PLASTIC 911.NONE 99,OTFIFR(Specify) JbOI <br /> FILL aMPONENTS INS'I'ALLFn ❑ LSPILL BUCKET ❑ .1.5'I'IUKFR PLATEldOTTOM PROTEL'I'UK 4.CONTAINMENT SUMP <br /> VII,UNDER DISPENSER CONTAINMENT(UDC) 464, <br /> CONS RUCTIONTYPE ❑ 1.SINGLE WALL Q 2.DOUBLE WALL ❑ J.NO DISPENSERS Q 90.NONE <br /> CONS ItUCTION MATERIAL ❑ <br /> LSTEEL ®J•FIRERGLAS$ ❑ 10.IUGID PLASTID ❑ 99.OTHER(S cif l Jmo-e <br /> VM. CORROSION PROTECTIpN <br /> STEIR CUMPONEN7 PROTECTION Q 3.SACRIFICIAL ANODE(S) ❑ <br /> a.IMPRESSED CURRENT ❑ 6.ISOLATION JJk' <br /> IX. APPLICANT SIGNATURE <br /> CER FICATIONI I certify the[this UST System is compatible With the hazardous substance stared and that the Information provided herein Is true,Occuralc, <br /> and in ful m lienee With It•al re mremeo Jin, <br /> APPIGNT SIGNATOR= DATE 5119(2009 <br /> APPLICANT TITLE <br /> APP ICANTNAME(Prim)STEVEN RAV U ER REGULATORY COMPLIANCE MANAGER <br /> Rev.(1221107) <br /> UPCF UST-11•112 <br />