Laserfiche WebLink
UNTIED PROGRAM CONSOLIDATED FORM <br /> UNHERGROUNDSTORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Oae ToNzn pa UST) <br /> TYFE OF AvmN (Chack one fxm only. Fm a S T donne or remoroi.complsa OWY floc cecdoa and Sm-MM I.It,UI.N,aed Lt bdme1 4w <br /> ❑ 1.NEW PERMIT B 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT C!QSSU DATBEXISTING USTD8.LIST .RE'.OVAL 4wa <br /> DATE UST PEKMAN8N ILY CLOSED: <br /> IN <br /> I. FACILPI'Y FaR1YtATION , <br /> nn. 1: <br /> FACILITY ID#(Agency Use 01111Y) 1. <br /> T -'- �' 7 <br /> 3. <br /> BUSINESS NAME(Sante m Fad&y NaMle 9r DBA-Doing 8minas As) <br /> J flc- n <br /> BUSMESS SITE ADDRESS X03 BUSINESSSf�fE�C[JT,Y 101 <br /> h.eDfllVf r>,�I _ <br /> IL TANICDESCRIPTION <br /> TANK ID# $, 432. TANK MANUFAC[l1RER 4 .. TANK CONFIGURATION:THIS TANK IS 4)4 <br /> I h G i ❑ 1.A STAND-ALONE TANK C momma,c.� <br /> Th r 3 e .ONE INA COMPARTMENTED UNIT etyrn�n m <br /> DATE UST SYSTEM INYI 3 TANKCAPACITYINUALLONS NDMBER OF R4THE\SN1T a3x. <br /> d peso <br /> III. TANK USIA AND CONTENTS <br /> TANK USE Ie.MOTOR VEHICLE FUELING O Ib.MARINA FUBLINO O <br /> 1c.AVIATION FUELING <br /> 439. <br /> 0 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(lede6.U OB) O 5.EMERGENCY GENERATOR FUEL W 124813()) <br /> 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER(S 'W: 44R <br /> CONTENTS PETROLEUM; 0 1..REGULAR UNLEADED O Ie.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED <br /> k]'3.DIESEL 0 5.167 FUEL 0 6.AVIATION GAS ase <br /> ❑ B.PETROLEUM BLEND FUEL O 9 OTHER PETROLEUM <br /> NON-PETROLEUM: 7.USPD OIL -� 10.ETHANOL <br /> I I OTHER NON•PEfROLEUM l8 <br /> IV. TANKCONSTRUCI'ION. <br /> TYPE DF TMX L SINGLE SPALL .DOUBLE wAll 0 95UNKNOWN iNl <br /> PRIMARY CONTAINMEM ❑ T smEL W3.FIBBRG`LASS 0 6.INTERNAL BLADDER 44w <br /> 0 7.STEEL+INTERNAL LINING 0 95.UNKNOWN 0 99.OTHER(SPcily): __. . <br /> SECOt4DARY CONTASWMENT O %.STEEL 12'S.FBP,RG(6SS 0 6.EXTFBIORMEMBRANELRNFIt 0 7JACKETED 410a <br /> 0 90 NONE ❑95 UNKNOWN 099.DINER(Speei$'): <br /> OVERFB.LPREVENIION OI.AUDIBLE B VISUAL ALARMS 02.BAU.FLOAT 03.FILL TUBE SHUT-oFF VALVE <br /> 451. <br /> i.TAAP:#METS EMS FOR EXEMPTION <br /> OVERFILLPRE.VEMION UIPMENT <br /> e FPDVCjrIWASTE PMM CUCTIUN, <br /> 474aNGCOIN5IRUCT70N %.Sa"'EWALL i3q.DOURMWAIL 099.OTHER <br /> SYSTEMTYPE (.PRESSURE2.OR WITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION 2308 T63id(3� <br /> PRIMARY CONTAINMENT 0 1.STEEL Er !FIBERGLASS 0 8.FLEXIBLE [110.RIGIDPLASTIC . <br /> Q 90.NONE 0 9s.uwmowN 0 99.&MRS /. <br /> SECONDARY CUNTADIkfNI 0 1.STEEL O 4.FIBERGLASS 0 a.FLEXIBLE 0 m ium PLAsnc 46tk <br /> 0 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Spediy): 44ic <br /> PIPMG/IVRBINE CONTAINMENT SUMP TYPE Q 1.SINGLE WALL 2.DOUBLE WALL 90.NIom 4fAt <br /> VL 'v$N VAPE► `RW(YV=T,(M)°AND RISER PFILL ME.PII!ING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 L STEEL 1Z4.FIBERGLASS 0 10.RIGID PLASTIC 090.NONE 0 99.OTIIBR ft0C y): <br /> VENT SECONDARY CONTAINMENT 0 1.STEEL 0 10.RIGID PLASTIC _13 90.NONE ❑99.OTHER(SpaY1y1: <br /> VR PRIMARY CONTAINMENT OLSTEEL 0'4.FIBERGLASS 010.RIGIDFLASTIC []90.NC1NE t]7/.(7S1iBRlSpziM: <br /> VR SECONDARY CONTAINMENT 0 1.STEEL a 4.FIBERGLASS O 10.RIGIDPLASTIC ❑ 90.NONE ❑99.oTxER(Speciry>: <br /> yENT Pmm 7vAmmDNSEfMP rr E _--- Q I.SU40LE WALL CrY.DOUBLE WALL ❑90.NOW _ _ - <br /> RL4ER PRIMARY CONTADIA T ❑ 1.STEEL ®'4.FIBERGLASS 0 l0.RIGID PLAS11c 13 90.NONE 0 "-OTHER(sPw*): <br /> IDSERSECOINDARYCONTAiN78EfTS (3I.9T-.vL 4.F%V&CLAR9 6 +o.R%GmPtnsnc 090.NONE 099.OTKER(SgmcdyI: <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATFIBOTI'OM PROTECTOR 0 4.CONTAINMENT SUMP e'6 <br /> VA LIMER'DISPENSER NTAI�ihMN3 <br /> CONSTRUCTION TYPE 1.SINGLE WALL _ 2.DOUBLE WALL 3.NO DISPENSERS 090.NON-469._ <br /> CONSTRUCMN MATERIAL 0 I.STEEL Cr4.FIBERGLASS ❑ l0.RIGID PLAsnC 0 99.OTHER(Specify 46% <br /> VIII, CORROSION PROTECTION <br /> STEEL.COMPOMENTPROTECTION 2.SACRIFICIAL ANODE(S) U 4.IMPRESSED CURRENT 6.ISOLATION Ne, <br /> IX. APPLICANT SIGNATURE <br /> CERTHIICATION: I certify that tits UST Wstem it eomPat bk with the hRrardWif NubstaRa Noted and drat Me 3aka IJPR Pnvided hate1R k trRe, <br /> ucRra and In fRBeo legal witk leuireatents. <br /> /( no. <br /> APPLICANT SIGNATURE DATE - ,V J <br /> APPLICANT NAME(print) mi n�. .APPLICANTTTILE ��Pt,i.7t�rU�J 472 <br /> UPCF UST-B Rev.(12/2B0'n-1/2 www.unddomorg Effective 01/17/08 <br />