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NOV-13-2013 15:10 From: 2096254549 To:4693433 Pase:1W19 <br /> RECEIVEDy <br /> NOV 12 2013 <br /> `S-ENVIRNME� <br /> HEALT RTI <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> _ OPERATING PERMIT APPLICATION-TANK INFORMATION(of tom,pa UST) <br /> TOIIACMNC3 NEW PEKMIT(Cheokone QeSlr only. Foran UST PRrmanbnt elm"or removat,mm*w only this stetion wd Sectiaras <br /> 3.RENEWAL PERMIT T.4 LB,tv,ana rX below) nF <br /> 6.TEMPORARY VST CLOSURE 7 UST PERMANENT CLOSURE ON SITE 11 5.CHANGE OF INFORMATION <br /> DATE UST PERMANENTLYCLOSED. mo. 11 S.UST REMOVAL <br /> DATE EXISTING UST DISCOVERED: clap <br /> FACILITY ID x(AS*^Pr U+R Onb) I. FACILITY INFORMATION <br /> BUSINNAME( as ACLF,pLITY or DBA-Doing Bustresa qs) 4 <br /> BU$RtE55 SR(Ad e S .401\ '0 �q5" <br /> t) CITY rnCYKTr� G �y.7,'.S�pa <br /> i TANK iC m5 IL TANK DESCRIPTION <br /> TANK MANUFACTURER e55 TANK CONFIGURATION:Tics TANKIS <br /> /J''J /�5•.� /� �❑I S 1NA OOW TAfP <br /> ✓��`-� �'�� ��"�.. 17�.�'a 141 A COMPgftTMENr£O UNIT <br /> DATE UST SYSTEMIN3TFLI,LED 655 TANK IN GALLONS 06 NUMBEROFCOMPARTNIE7JTSINTHEUMT437 <br /> TANK USE f YM`OTOI `ftivaluClE FUELWG UI.TANK USE AND CONTENTS <br /> ❑ IbMARMAPUBLBdCI [] <br /> J,CHEMICALI4 AVIATION FUELING 'kK <br /> PRODUCT STORAGE 0 d HAZARDOUS WASTE N+d.dn uma pry 0 5,EMERGENCY GENERATOR FUEL <br /> ❑ &0TIHEAGENERA RFUEL 95.UNKNOWN I'R`)) <br /> CONTENT$ PETROLEUM: �R()M,p,6D 99.Oiemt G i na <br /> (] ic.AOD(JRAOE UNLEADED Q Ib.PREMIUM INLEAOED a6P <br /> ll1E3EL 0 5.JET FUEL ❑ 6.AVIATION GAS <br /> V S.PETROLEUM BLEND FUEL Q T.OTHER PETROLEUM 3 ddb <br /> NON-PETROLEUM.[] USED O 10.ETHANOL <br /> 11 OTHER NOW.P OLEUM 3 <br /> IV. TANK CONSTRUCTION �c <br /> P£DP TANK 1 SMGLP WALL 2.DOUSLEWALL 95.INI(tJOWN <br /> PRIMARY COMAINNffiNT 1 STEEL .FIBERDLASS Kt <br /> r.STEEL* e.INTERNAL BLADDER dw <br /> J SECONDARY CONTMNMENT DOF,xNAL LtNMG Q 95.tJNXNOWN 1U3 "D'n�'A e6Y <br /> Q l STEEL ❑1.FpJERCLASS 6.EXTERIOR E L ER ❑ 7.lACdCEIFD u9 <br /> Cl 9a. NE 0 95.UNKNOWN 99.OTHER $ i <br /> OVERFHL N .AUDILE&VISUAL ALAEMS O2.RALL FLOAT __ <br /> $ a5e <br /> Q <.TANK MEL"IS ITS UUW1vtENT$FOR GXEMPnDN tl�r�FILL FROM OVERFILL PREVENTIONUIPMENT LVa +zi <br /> V. PRODUCT/ STE PWING CONSTRUCTION <br /> P@MGCONSTRUCTION i.SMOSURIS f.FD VELE-WALLED 99.OTr�R <br /> SYSTEM Tt'PS <br /> PR4MAftY MNTAINME4IT 02ORAV4TY 03.CONVENTIONAL,SLCnON 4.SAF£SUCITON I2J CCR Jai 658 <br /> ❑ 1.STEEL GLASS s,FLEXIBLE 10.RIGID PLASTIC l66 <br /> ❑ 90.NONE ❑ 95,UNKNOWN 99.0THE <br /> SEMNDARY MNTABR.fEN7 I.8 - ERGLASS 8.FLEXIBLE <br /> 0 90.NONE 0 95 UNKNOWN {] 99.OTHER soca 0 J .RIGID PLASTIC es4 <br /> IPMG/IVRBINECONTAINNffiNT$ TS'PE GL8w 99 O HERRLE WALL ctrc <br /> VL VENT,VAPOR RECOVERY 0 90.NONE .we <br /> a "641T PRIMARY coNTArFrM6TrT (VR)AND RISER I PILL PIPE PIPING CONSTRUCTION <br /> 1 STEEL B. IEERGLA 5 0.Rl ID PL 901,NONE 99.OTHER(Sowi6) 1 e <br /> Y.N'rS ONOARY CO AWNffiNT _ gT&EL d Pf66RGLASS [] to.R1GID PLASTit6Mel <br /> YR PR Y MNTAINMENT C] �.NONE 94.OTHER(Specify) cMf <br /> C jd I.STEPJ, FrgERGLASS l0.Ri0 PLASTIC 90,NONE 99.OTHER(S"a fy) wn <br /> 1 +R SeCONDARY MNTAJNMENT - <br /> L A STEEL a FIBERGLASS n.RIGID PLASTIC L] .NO $99.OTIR�R <br /> Y�PIPBJG TRANSTDONS TYP6 ( pew <br /> f �R196R PRBMRY CGMAMMPNT 1. GE WALL 2 pOVHLS WALL .NONE +Nhl <br /> 1.STEEL ❑ 4.FTRERGLA33 10.RrG1D PLASTIC so.NONE16fz <br /> 10.13ER SECONDARY CONTAWmINT I srEEL d <br /> 99.01"M(Epepiy) � <br /> FR)ERGLA$S 10.R1GID PLASTIC 90,NONE Q 99.OTHER(gpal(S,) eyy <br /> fLL CO INSTALLED 1.SP LBVCKBT ssTanegRruTE/SarrpNP TSL-taR e.CANT <br /> .UNDER bI5PL4N5ER r mar s °(6ul <br /> CO NSTRUCTION TYPE -.fie A ,`INMENT DC <br /> �L CNS ONMATWIAL 'S I, WALL .U6 PLASTIC <br /> 91 No 9,07M9PENSERS 9o,NONa .ee. <br /> ' TEEL d ERGLASS 10.RR'sID PLASTIC g9.0'DIER <br /> VIII. CORROSION PRO �a0bi <br /> STEELCOMPOFIENT PROTBCTroN 0 2.SACRJFICIAL ANODF(S) ❑ d, <br /> ON 11R <br /> CBRIX. APPLICANT SIG TUBE <br /> TTF/GTTON:T ce.d;(y mat tbq UST systcm,y o Patsblc>rith We AaEaTAORs Saba ce sWry��yogT1Y <br /> and is mN ee lienu wi>;b 1 ireplcntl. 1Yll thl&rmm p �helaaa 6l,Tw aecontq <br /> APPLICANTSIGN <br /> I� DATE .>a. <br /> A PPI 1leaf-r v,e ... D <br />