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NOV-13-2013 15:10 From: 2098254549 To:4683433 Pa9e:9�19 <br /> RECEIVE® <br /> T4;48 X1.2 0' <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> OPEUNDERGROUNDSTORAGETANK ENVIRONMEN L <br /> RATING PERMIT APPLICATION-TANK INFORMATION Onc fmddPAUH DEPARTME <br /> P T <br /> TYPE OF ACTION (Check ore item only, For do USi permdnmt c199utt o.reluoval,rantplete only iWs section d.M Secaans 1,H,111,N,entl 1X IuWw) n9 <br /> N6W PERMIT 11 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 1 <br /> 16 7EMPORARY UST CLOSURE [3 T.UST PERMANENT CLOSURE ON SrM ❑ S,UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43°eI DATE E)(LSTING UST DISCOVERED: dl(o <br /> I. FACILITY INFORMATION <br /> FACILITY[D d(Agenry Uu OBlyj <br /> - J <br /> BUSINES W( �ACI,ITY INA,pIE ar DBA-U0i 9 Business As) <br /> eBd�J CeI✓ Wus 1 <br /> BUSINESS SII gTg , los CITY <br /> =I DD �*A-P <br /> TANK I4" .Jx It <br /> TANK DESCRIPTION <br /> (, TAANNK/M�ANUFACT-1 .s T©ANKOONRIOURA'RON' TMTANK 18 aJe <br /> D/,) (A02ZONE w gwcoMPnAYMBNsso UNIT. <br /> DATE UST SY IFISTALLED s TANK [TT M GALLONS os NUMBER OF COMPAATMENTS IN THE UNCI n <br /> TANK us6 ��Mp�RjTpR yr�ticl,E PUFyuNO UL TANK.USE AND CONTENTS <br /> 3.CTffNQCAL PRODUCT STORAGE Q !e.MAA 1, FUF,LMG U In.AYµT10N PT1EI-TNG ITS <br /> 6.OTHER GEN ERA FUEL 0 n.HAZARDOUS WASTE(Wtlu o,l) ❑ S.EMRAGENCY GENERATOR NEL(JPO Nsxsl Xc)J <br /> CONTENTS PETROLEUM, El 95.UNKNOWN O 99.OTIER S <br /> .DIESEL" ❑ lc.6GAORADE UNLEADED U In PREMIUM UNLEADED deb <br /> U 5 XT NEL U 6.AVIATION GAS <br /> U e.PETROLEUM BLEND FUEL q 9.OTRERPETROLEUM a0. <br /> NON-PETROLEUM:❑ �.USED 02 p JO �� <br /> Il OTHERNON-PEPROLRUM S 'Jy, <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK I.SMQLE WALL 2.DOUBLE WALL 95.UNKNOWN <br /> vRIMABY CONTAINMENT d I.STEED, 3.FIBERGLASS U 6.INTERNAL BLADDER <br /> .0 <br /> ALL STEEL+INTERNAL LININGt11 <br /> ❑ 95,UNKNOWN ❑ 99,OTHER yp <br /> SECONDARY CONTARIMENT U 1.go ND S. .UNKNLASS 6.ECCERIOR MEMBRANE SR 9.JACKETED us <br /> f'i ❑ 95.UNKNOWN 99.OTHER R <br /> Dv ILL PREVEN'r10N . rAN MEBt VISUAL ALARMS 2,EALLFLOAT +U. <br /> l Q a.TANK MEETS .EA,L TUBE SEN{' VAL OSx. <br /> l REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION UUsME1N'T <br /> V. PRODUCT!WALSTE PIPING CONSTRUCTION <br /> Ptp[NO[ONSTxU ON QlSWGLE ALLED UBLE-WALLED 99.07HER <br /> SYSTPNA TYPE ESSU 2.GRAVTTY <br /> PRNRARY CONTAINMENT I.STEEL SCONVENTIONAL SUCTIONg a,SAPS SUCTION nrm <br /> 1390.NONE FROLASS 8.FLEXIBLE q I0,MI PLASTIC w <br /> SECONDARY NTAINMEN1 I.STF$4 U 95.UNKNOWN Q 99.OTp, wa <br /> Q 90.NT)NE S.FLEXIHLS UID.ALGID PLASTTC 464 <br /> PRINC/T'URRDNE CONTAINMENT SUMP TYP6 U95.UNKNOWN 99,OTHER(Sven ): a6ac <br /> OLE WALL E.DOUBLE WALL ❑ 9D,NONE .au <br /> VL VENT,VAPOR RECOV$RX(VR)AND RLSER/FIx I PIPE PIPING CONSTRUCTION <br /> TENT PAJMARY CONTA I.S Q n. PaiGU95 10.RIGID PLASTIC <br /> VgNT SECON AR7 CONTAINA9EDfi 1590.*JONB 99,OTHEB(SpaiPy7 ..., <br /> r i _ I.STEEL 0.FTBEAGLASS l9, m PLASTIC Q 90.NONE ❑ 99 OTHFA(Svecb) R.f <br /> Vft'RAfARY CONTAJNMEMI � t.STEEL a.FIBERGLASS 10.RIGID Pl.AS7T 98,NONE 99.OTHER(Sp�♦a,) aSIS <br /> d ' <br /> RS NM3ARY CONTAWMpJI I.ST£EJ, d.pIBERCLAg3 Q J9.R101O PLn3nC 1 <br /> 9n. B ❑ 99.OTHER(Spadry) A'M <br /> Y PIpfMG SITTDN I)!AP'[yyE 1.sir! , <br /> PRIMARY CONTAINMENT 1 STEEL ❑ 1.FIBERGLASS 1.UOU LE WALL NONE . <br /> 10.RLGLD PLASTIC 90.NON6 99.OT'WR(SPmiCyJ .69 <br /> NdEX"CONDARY L'pNTAINM$N} 1.STEELdill Ffs4"1 <br /> l0,RJO PLAS IC 9p_NONE 99,pTT¢R MOW a6.Y <br /> PI L COMPONENTS INSTALLED L$PILL UCKEL :1 : :;:; PLAIFJRO'FfOp,I JAJO'JyCI'OR ❑ a.CDNT <br /> .UNDER DISPENSER d.'`. gam' .x�.r <br /> CONSTRUCITON TYPE UNDER <br /> �-•+/ <br /> L. cor+dTnL,cn I.E <br /> WALL <br /> A 9 IEERGLASS �ttBLE WALL g3N0 DISPENSERS 90.NONE aee. <br /> 10.IU ID PLAS C 99. THER S t <br /> PROTBCTpN <br /> VIIL CORROSIONPRoTECTION <br /> STEEL C06IOT1FiNT U 29ACRL%C1At.AJ"OOE(g) <br /> d a.R.vBFSSEp cuRAENT ouTtOry .0 <br /> CRR WICATTGN: I cerRFy ftt m�usr M APPLICANT SIGNATU <br /> Bad iA fP8 SS'9tem is eompephM with the kaaa avas wba4om Bm •. <br /> 1�ce with kalomts. a 9cunt <br /> APPLICANT SIGN <br /> DATE lk % J. I OV 1 7 2tl13 e <br /> APPLICANT NAS ,,C t, 471 <br /> L~ ril/U c- P .W�9,bCEJ� MP[.ICADST g ni,� <br /> UPCR UST-B-U2 (f <br /> RI*.(121207) <br />