Laserfiche WebLink
AWL <br /> IED PROGRAM CONSOLIDATED FORW <br /> UNDERGROUND STORAGE TANK �Yp7�' <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per1Usp`µ\��` <br /> � <br /> TY OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,17,111,IV,and IX below) 430. <br /> 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID 4(Agency Use Only) _ _ I. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business ) 3 <br /> N . <br /> M� �cA ILwtK SV <br /> BUSINESS SITE ADDRESS 103. CRY 104. <br /> XM €, YoCArn � <br /> �TF k ' M�tN1 ��t, Ch • a5;3;�)(Q <br /> II. TANK DESCRIPTION <br /> TANK ID#Q O ff <br /> 432 TANK MANUFACTURER 433- TANK CONFIGURATION:THIS TANK IS 434. <br /> ❑ II-A STAND-ALONE TANK Comp1eteonep.8e1ore.ch <br /> Ea'2.ONE IN A COMPARTMENTED UNIT compenment in the unit. <br /> DATE UST SYSTEM INSTALLED 435, TANK CAPACITTYQIN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437- <br /> 61 0 <br /> III. TANK USE AND CONTENTS <br /> TANK USE 3r Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL TSC§25281.5Py <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN .❑ 99.OTHER(Specify): 439.. <br /> ___. ..__.._... <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED Ic,MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. <br /> ---------------.......__.._.-._..._.._____________...._.........__ ....... <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ I1.OTHERNON-PETROLEUM(S eci : 4401. <br /> IV TANK CONSTRUCTION <br /> TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL E] 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT 1.STEEL ❑ 3 FIBERGLASS ❑ 6 INTERNAL BLADDER 444. <br /> ❑ 7.STEEL,INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTFIER(Specify): 444.. <br /> _ _ ___....._-_............................-.___ .._...____._.-_-......______.._._. ...._.........._.....445 <br /> SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ fi.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445.. <br /> PRPP_.. <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT J3 3.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> PRPP ........ ...... .... ...... __________________________-___-______-_- <br /> .SYSTEMTYPE I PRESSURE .❑ 2 GRAVITY ❑J CONVENTIONAL SUCTION ❑ 4 SAFE_SUCTION[23 OCR§2636(.)(3)] 458 <br /> PRIMARY CONTAINMENT ❑ I.STEEL ,)�4.FIBERGLASS Co- 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify) 464.. <br /> .....___ _______________________ __ .._.._....__._. PRPP _________ ._.....-_. ........PRPP <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4641_ <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> N ___. . UB .. ....... <br /> PIPINGII'URBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46aa. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL 314.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): J4Me <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): 46,M. <br /> _ _ ____ ____ .-....... .... <br /> VR PRIMARY CONTAINMENT ❑ I STEEL )y 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): 464g. <br /> __.-------------__ _. _____.- ........ _.________C'_`____________ _ RdIal,... <br /> ... __ _ _..PRPP_ __._.PRPP PRPP__.._ <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): _-4 64h. <br /> ________________________________ __________ _________.........._..__.._._.._._................ ......_...;_... <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 2'90.NONE <br /> -.._. __------------------,___..__ __ ..... _.._....-_____________ _ ___ ... ..._...............60.. <br /> RISER PRIMARY CONTAINMENT Id I STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify): 464 i. <br /> �­------------------------ ... ... .___ ________.______________________.PRPP_ _. 464,4. <br /> RISER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS 0.10 RIGID PLASTIC �90 NONE ❑ 99.OTHER(Specsfy): 464,41 <br /> .___.___.. ._... ___________________________ .. <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ec. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE I SINGLE WALL 0 2 DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90 NONE 469.. <br /> ....... PRPP. ..._._.. ... ........... _ ......_ .. ............. .............. ..... . ................. ............... ............ . .. .... ...--.........---.. . ..... <br /> CONSTRUCTION MATERIAL ❑ L STEEL 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER(Spemfy) �,� 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 44e. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, <br /> accurate,and in full tantapUjince with legal requirements. <br /> APPLICANT SIGNATURE DATE Q / 470' <br /> APPLICANT NAME(print) °71' APPLICA T TITL 902' <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org <br />