Laserfiche WebLink
0 o a -icry <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Gaa ra Per SI) <br /> -" TYPE 017 AC170N ((.'heck one item only. Tor a USY closure or remornC cornplefe only Ills seelim and Sect01'sI,IL IO,IV,nad IX helol49 ma <br /> I.NEW PERMIT Cl 3.RENEWAL PERMI-I ❑ S.CHANGE 017 INFORMATION <br /> 6.TEMPORARY UST CLOSUIdE O T UST PL•RMANENT CLOSURE ON SITE 8.U""' OVAL <br /> DA'I'S UST PERMANENTLY CL 0: NOa. DATE EXISTING UST DISCOVERED: uca <br /> I. FACILITYINFORMATION <br /> FACILITY IDP(/,,gene/'i/seO4;(y) 1' <br /> BUSINESS NAME(Sante ns prtcifi0:Nnmc a•DRA-Doing HusinessAs) 3, <br /> 2tS/OE/l�C€ <br /> 13USINESS SI'Z'E ADDRESS Im. Carj3. A <br /> Ia. <br /> O S TOG 7 >'TANK IDd 432 'TANKMANUPAC IURERK CONI'IGW,ION:THISTANK IS434, <br /> ASPAND-ALONE TANKONE INA COMPARTMENTEDUNITDAT'L• S'1'SYS'1'IiM INSTALL D 435. TANK CAPACITY IN GALLONSBER Oh COMPARTMENTS IN ff <br /> T(il°UNIT 437, <br /> III AN#USE ANAi.ib. N-T TS <br /> TANK USE ❑ to M01)ORVEHiar.rUEum U Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ yCHEMICALPRODUCT STORAGE 04.HAZARDOUS WASTE(InchHoUs<d Dip 0S.EMERGENCY GENERATOR FUEL(IISC F352865(c)) <br /> 6.OTHf;R_ GENER_ATOR FU M- -_ <br /> 0 <br /> 95.UNKNOWN <br /> UInREGUAR UNLEADED ] IcMIDGADEUNLfADED ❑x"9Ib9.PREMIUM <br /> S)3UccNifLy)iA/77/E�D TDf a434�0'+.-_NFENTS PiTROLLBSL <br /> 7 DIESEL I] S On I'UEL ❑6 AYIn'f1UN GAS <br /> ,,,, _.......__, 7ATgu68. LELIM ------UCL ❑ 90n{CRPETROLL•UM(Sp SE,K 44.0 <br /> NON-PCTROLLLIM:❑ 7 USCI OIL��'� �_��LEND --- �--._. <br /> ❑ I1.0'rHC•R NON-PETROLC•UM S ccif 440p <br /> V. TANK CONS, C-,T,ON . <br /> TYPE Or TANK_ LSINGLE WALL ❑ 2_DOUDLE WALL 75.UNKNOIVN _ 443, <br /> PRIMARY CONTAINMENT -_ I.STEEL. - 03.FIBERGLASS ❑ 6.IN'rCRNALSLADDER - ---__,-_ _- --- ------- 444. <br /> _o 7.S'IEL•'L 4 INTERNAL LINING _ _❑95.UNKNOWN I] 9-. ( eci��: 444a <br /> SGCONDARY CON1'AINMF:N'f ❑ I.STEEL [13.FIBERGLASS ❑ 6.EXPERIOR Mr:MBRANE LINER ❑ 7.JACKETED <br /> �90.NONE ❑ 95.UNKNOWN ❑99,Ort{GR(SpccifyZ wia. <br /> '- OVERFILL PREVENTION ❑ LAUDIBLG&VISUAL ALARMS ❑ D.BALL FLOAT ❑ 3.FILL Tl1S1'SHUT-OFF VALVI! n5i. <br /> Qj 4 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION B UIPMEN'I' /�/ <br /> " V PRQbUCT/+WASTE PIPING,CONSTRUC, ION .. <br /> _SYSTEM OY�EfRUCl[ON_,� 1.pAESSURIAtl � 2,C7RAUVITY PALL �yCONVEN770NAL SUCTION,le-4_SAI'BSUCfION1uCCR_§363d(aZp)L__ 45&� <br /> PRIMARY CONTAINMENT 0,1 STEEL ❑a FIBERGLASS ❑ E rimmu ❑ 10 RIGID PLASTIC -isi. <br /> 90 NONE ❑ 9S.UNKNOWN ❑ 99 OTHER 46ga <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ a.PIBBROLASS ❑&FLEXIBLE ❑ 10.RIGID PLASTIC <br /> 90.NONG 95.UNKNOWN ❑ 99.0THRR S ccif q6q< <br /> PIP]NG/7 URBINC CONTAINMhNT SI IMP TY PE ❑ 1 S1NGLr well ❑ 2 DOUBLE WALL. <br /> ,,M .-L. ©R COVERT i� R AI$D RISER/FILL PIPE PIP.INCON$TRUC ION <br /> VENT PRIMARY CONTAINMENT W1:STEM ❑ 4.FIDEROLASI ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.0THER(S ecif : 169c' <br /> ....... _..._ ...... '-------- -.-...__... ----'- n r) 4x441. <br /> VENT Sl CONDARY CONTAINMENT ❑ 1 STEM. ❑ 4.FiBERGLASS ❑ 10.RIGID PLASTIC W0 NONE ❑ 99,OTf1-R(Specily)- aaa. <br /> __.._. .__ _�. -- -- <br /> _ ......__.._-_._.__...__.._.........._._..-_......._...___..____...____._..__._.__...__._.___....._.___..... .. <br /> VR PRIMARY CONTAINMENT ❑ I.STEEI. ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC Y,90.NONE ❑99.OTHER(Specify): 464% <br /> VR SECONDARY CONTAINMENT' ❑ I STGBL 1. <br /> - - 4164 <br /> _ ❑ 411DERGLASS ❑ 10.RIGID..PLASTIC �90 NONE ❑ 99,DIILR(Specify): 4646"._ <br /> VENT PIPING I RANSITIONSUMPI'YPE ❑ I.SINGLEWALL [I2.DOUBLCWALL o". <br /> RISER PRIMARY CONTAINMENT LST'Erl ❑ 4 FmERLLA55 ❑ 10.RIGIDPLASTIC J]I NONE ❑ 990THER(Spocify): a6J+ <br /> _ .. ..404} _ <br /> RISER SECONDARY CONTAINMENT!' ❑ I.STEEL 04,FIBERGLASS ❑ IO.RIGIDPLASnC x!'90.NONE ❑99.OTHER S °646' <br /> W ( pedry)' 464k1. - <br /> FILLCOMPONENTSINSTALLED O I.SPILL BUCKET ❑ 3.STRIKERPI.AlfMO'rl'OMPROTECI'OR LI4.CONTAINMENT SUMP 45Isa. <br /> VII. UNDER JMPENSER,Q0NTfiAI}1?1kIENT(UDC) <br /> --- <br /> --.._ ❑ I S t Q r I17E t(I ASS ❑ I0 721(„D PLASTID "- ( ) _. ^ NONE 4m.. '- <br /> CON_I11 I01'[tIl IvGI_C, 16 0 2 DOUBLE WALL ❑ 3 NODI L`AIItS _ <br /> (ONS L,UC I ION MA l I,d1AL ❑ S DISI ❑ 9.0"I};R Sp it��: <br /> _ 469, <br /> VIII. CORROSION PROTECTION <br /> STEELCOMP0NLNTi'R0'IIiCII0N O 2.SACRn IrIAL AKODE(S El 4.IMPRESSED CIRRLYr ❑ 6ISOLAION 418., <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that tl' "syale 3)s p c with the hazardous substance stored amt that Tho in form of ion Provided hermn n nue, <br /> accurate, m s n al a nirmnents. <br /> APPLICANT SIGNATU DATE (7i_30 �/ J70 <br /> _ API'LICANT'NAML•(prinQ/ <br /> �yl�C )O �y7 4T" APPLICANTTITLLEE •7 X72', 954 <br /> UPCF UST-BRev.(1212007)-I/2 (' r`www.m"idocs.org <br /> Y� <br />