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NDV-13-2013 15:11 From: r 2098254549 � I\IF' l Pa9e:11,`19 / +%0 ] 2 2013 Ta� to FM UIv1FU D PROGRAMUNDERGROUND STORAGET MIRM IMENTAL L'NAERCROUND STORAGE TA DEPARTMENT OPERATING PERMIT APPLICATION-TAMC TION(o t Fpem vu UST) TYPE OF ACTION (Check one iteas my Fpr an LIST sxTMsananT closure M rem0+�a1,wmplote ony dAts axtion and Seotiops 7,H,Ip,IV,and IX MAow) eto � 1 NfiW PERMIT 3.RENEWAL PERMIT d,TEMPORARY UST CLOSURE 7 UST PERMANENT CLOSURE ON SITE 11 5•CHANGE OF INFORMATION i AA TE UST PERMANENTLYCLOSED: 450, B.USTREMOVAL DATE EXISTING UST DISCOVERED. 430b L FACILITY INFORMATION � FACILITY 0 d(Agaxy U44 Ony) BUSI[�S ( as pA i'TTYY NAtr1);or DBA-Doing BusinPsa As) t .ZB C'av IetI�YSYA ) BUSINESS SC)'T,ADWE; �._'-t- J _ 10 CITY OWE;f�ii a.wlr[ iPs...P' TANK IC" ¢ p 1I•TANK DESCRIPTION 0 96 U 3 / (0 aa2 TANK MANUFACTURER "ls tANKCONPICUaATTON'. Tws TANR t9 V / o L❑1 STAND-ALONE PARK ONF)N A COWARTWENM UNIT. �DaTE UST SYSTBYfJJSTA4LED ns TANK�atpACCfYM GALLONS +ta NUMBEROF COMPARThENTS IN TNEUNrTuv TANK uSE III/4M4-oTTO V6FDCLb FUEL NG (J 1R'TAMC USE AND CONTENTS C7 3 CHEM CAL PRODUCE STORAO£ [I 66.MAR NA FOP NO ❑ Ic.A ViAT10N PUE kJG )9 []6.OTHER GENERA RFUEL Q .HAZARDOUS WASTE(.dWa Uwtl OY) 115.EMERR CYGENkRATOR FUELS VI s(P)I CONTENTS PEIROCEIIM. L7 95.UNKNOWN 99,OTHER 'Py): 43% fJLAR IfNLEAD i] Ic.M)AGRADk UNLEAAED � Ia.PREINUp1 UNI.EADep W 'Dom' ❑ S.fET FUEL ' � a.PETROLEVM BLEND FUE4 90TTiER PETROLEUM � aAVUTION GAS 1 NON-PERIOLEUM: �.USED OR. I �" {� ❑ I I.OTr{kRNON-PETROLEUM 10.ETHANOL 'YP of TANK �'. TANK CONSTRUCTION .A,. I S!N WALL 3.DOUELe WALL 95.UNKNOWN sq iP0.IWARY CONTwDWENT ❑ I.STEEL 3.PIEERGLASS � b.DrIERNAL BLADDER T,SIEFJ,�B'rTERNAl LINMG M° SECONDARY CONTAINMENT ! �7 95,UNKNOWN ❑ 99.OTtIEA 4y., i fT 9i0� LT S.FIgkRGLA3S 6.EXf£RIOR MEMBRANEL ETt T,JACRFFPp u5 OYERFlLLP ON ❑ 95.UNKNOWN 99.OTI{ER S ars. .AUDtEsc@VISUALµARMS ❑ 2.EALL FLOAT .PILL TOBE SHMCIFFVALYS est. ❑!.TANK I.Q£TS REejUIRkNn;N'TS POR EXEMPTION PROMOYkRPII.L 1'REVENTiON UWa/ENT V. PRODUCT/ PIPING CONSTRUCTION PIPMG CONSTROCTTON rOLE-WALLeD BLE-WALLEO aYSTEM TYPE RESSURE Q 2.GRAVITY [] 1.CONVENTIONAL SUCTION 11 4.SAF£SI I9ON N5 om rss PRIMAROTHER Y CON'fA1NMEM ❑ 1,ETEEt OIERC- B.FLggBLE ❑ 90,NONE (] 95.UNKNOWN ❑ 99.OT3fER CI to.wip PLASTIC ssa StiCOND&I CONTAJNMLWr Q t.STEPI, I. +sea eROLpSS ❑ B.FLEMLE IO JUMPLASTIC In90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Sp ): 4611)Pr?lNGrITRtEEJE CONTAWMENTSIJI dW TYPE a WALL 2.1)0-1EWALL .6u VI.VENT,VAPOR RECOVERY rvoNe a FaWM�nRY CONTAA WENT aRR)AND RISER/FILL PIPE PIPING CDN3IRUCTION �---^, t STEEL 4.FIBERGLASS ta.RIOm PL nc 13 W 140 E W.OTN£R(apaify) sae ENT SECONDARY CDNTA i.3tEEL 4.FIBERGLASS 10.RIGID PLAMC 's0`t R PRB.fARY CONTwDJA$Nr CJ 90.NONE 99.OTHER ear 6 )d 1-S1FEt a.FIRER A35 10.RlOID PLASTIC ONE 99.OTHER(Spxafy) VRS'eC.ONDARY CONrAWWNT I.STEEL p4.PISEROLASS Ip.RIC1D PLA$ 90.N W. VEND pike OTRANSITION WSER pRIMARYCONCAINI+TeNT I.S E WALL 2.1JOUBLE WALL .NO I.STEEL a.PISERG 10.PJO)D PLASTIC 90.NONE 0 >g,oTemt((SP••:4) s.N 0.i>11beCONDnRl'eONs!e !1; Tf G.ST' t. (BERG 1 $TIC 10.RI m pLA90.NONE 99,OTHER(Smfj) wst F111 I COWINSTALL D ISPILL BUCKET 3.STENSERR(KRRPLAT8160TTOM PROT£RO0. A,CONTASIVat4+T3UMP � UNDEII DISP .:. ssa. S3AFTAIIYMENT I1C) CON$TRUCTtON TYPE WALL cOrvbiBVCTION Mn L STEEL 4RIBERGLA33 luauIGMP WAl'L 3.NO DIS s69. AS VIIL CORROSION PROTELCT ON R STEEL coWPONP-trr PROTECTION ❑ 2.&ACRIPIOIALANODE(B) 04.1 IX. APPLICANT SI , LArIGN CYATIIFTCATION; 14wtify that this UST system u.empaNble wItb the bla Noce b set atpr�s p{pa( Aad m Tau rem to..ke mens. o provithd herPlS Y ttya accurate. APPLICANT SIGN 470 APPLICANT N pDnt),� -ck NLrCns 4 aFP CANT I 'iP .�Cde,FjgJ� UPCF CST-I.112 Rei'•(ti2p9't)