BILLING_2017 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections L IL 111,IV,and IX below)- ;` !.i 630 E] 1.NEW PERMIT [5 3.RENEWAL PERMIT [15.0 1tANGE OF INFORMATION ti.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UPREMOVAL 6306 DATE UST PERMANENTLY CLOSED: 0348 DATE EXISTING UST DISCOVERED: L FACILITY INFORMATION FACILITY ID A(Agency Use only) - - 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) BUSINESS SITE ADDRESS p� 7 o 1m crrY O� II.TANK DESCRIPTION TANK IDM 02 TANK MANUFACTURER C0 TANK CONFIGURATION: THIS TANK IS <fp© /10 ll! f7 ;334 I.A STAND-ALONE TANK O� D 'yW- 'ONE IN A COMPARTMENTED UNIT. c uroe9 rr4acnwo, en��aaK� D !!o DATE UQT 9V VI VM INSTAI.f.RD 4$5 IANYCpOpA I)�N�ALLONS 016NUMBER OF COMPARTMENTS IN 77iE UN C>:'�A}4r ©D� fIL TANK USE AND CONTENTS TANK USE a MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE 00midel Uaed019 ❑ S.EMERGENCY GENERATOR FUEL PVX 1252213(0)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED aea 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9-OTHER PETROLEUM S 6608 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS alOb IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN M3 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 666 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S ): 6Ha SECONDARY CONTAINMENT ❑ L STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7.JAC u5 ❑ 90.NONE 95.UNKNOWN 1199.OTHER S ): OVERFILL PREVENTION rUL 1.AUDIBLE&VISUAL ALARMS2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS OR EXEMPTION FROM OVERFILL VENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION [3_j.SINGL -WALLED .DOUBLE-WALLED ❑99.O1'Fff.R 660 SYSTEM TYPE PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123(XR 2636(a)(3 458 PRIMARY CONTAINMENT ❑ 1.STEEL Chd�'¢.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 666 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): ad1. SECONDARY CONTAINMENT ❑ 1.STEEL ICK4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC aeab ❑ 90.NONE 95.UNKNOWN ❑ .OTHER(Specify): 4W PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.MGM WALL 2.DOUBLEWALL ❑ 9o.NONE a d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT u 1.STEEL .FIBERGLASS U 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 6610 a41e1 VENT SECONDARY CONTAINMENT I.STEELip.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) a64f awn VR PRIMARY CONTAINMENT 1.STEEL .FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 6669 VR SECONDARY CONTAINMENT El LS L FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) a h 46ahl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL .DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC HU 90.NONE ❑ W.OTHER(Specify) a6ai 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) creak 461k1 FILL COMPONENTS INSTALLED 4ri.SPILLBUCKFT 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 4s3a< VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 6698 CONSTRUCTION MATERIN. ❑ 1.STEEL FIBERGLASS 10.RIGID PLASTIC 99.OTHER(S aa960 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION .SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 44E. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requiremeom a o. AP I NT SIG R� DATE RV1 I APPLI NT NAE(print) \ � a71. APPLICANT TITLE an. M UPCF UST-B-1/2 /� Rev.(1212007)