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9 <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One Form per UST) <br /> TYPE OF ACTION (Check one cern wdr. For a UST cloture or mnmvl,carrplere ar(r rins secnon and Secooru 1,11,111,17.mrd H belmi7 430 <br /> L NEW PERMIT [13.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.7EAIPOR4R7"UST CLOSURE 0 7.UST PERNLANENT CLOSURE ON SITE S.LIST REMOVAL <br /> DATE UST PERNI.ANENTLY CLOSED: 430+ 1 DATE E-MSTING UST DISC OVTRF.D: 43l <br /> L FACILITY INFORMATION <br /> FACI.HS ID e(dgenn i'sr Onh) _ 1. <br /> BUSINESS NAME(Same as Fuulm_'\-Dore or DB.4-DomgBnsmess 4 1 3 <br /> C M C <br /> BUSINESS SITEADDRESS10, cm 104 <br /> mz oe-C <br /> II. TANK DESCRIPTION <br /> T.-U&IDs 432 TANH:NiANU.IFACIURER 433 7.Yt4f:CONFIGURATION:THIS TANK IS 434 <br /> -7yao5(5$4`S })IDc�2 v w�� O< I ASTAXD.ALONET.AN1; <br /> 2 ONEINA 0A PARTMHNIIDUNIT cmapmaaeutm We mer <br /> DATE Lj�T,rSYSTEM( e 4 ST. LED O 31 TANK C ?.0�INGALLONS 436 NLTAJBER OF C'hfPARTMENTS IN THE UNIT 43- <br /> Trp'v e)- <br /> III. TANK USE AND CONTENTS <br /> T.ANELTSE F la MOTOR VEHICLE FUELING 0 lb.MARINA FUELING ❑ Ic AVIATIONFUEL]NG 439 <br /> 3.CHMCALPRODUCT STORAGE (3 4.HAZARDOUS WASTE faa,"u doh) ❑ 5 EMERGENCY GENERATOR FUEL[Nsc 3252815(e)) <br /> _❑ 6 OTHER GENIRATCrx FUEL ❑ 95 _IN124OVN ❑ 99.OTBERBR'nC5). 43% <br /> CONTENTS PETROLEUM la REGULARLNLE.4DED ❑ le MIDGRADELNLEADED ❑ Ib PREMRIMLNIEADED 440 <br /> 3.DIESEL ❑ 5.IETFLBL ❑6 AYIATIONGAS <br /> _ ❑ s.PETROLEUMBLE[,DFURL ❑ 9.OTHER PETROLEUM(Specdp). u� <br /> NON-PETROLEUM❑ 7.USED OIL ❑ 10.ETHANOL ------ <br /> ❑ 11.c)TBERNoN=oLEum(specdcj. 440E. <br /> W. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1 SINGLE WALT. a2 DOUBLE WALL ❑ )5 LINRNOYVN443. <br /> PRRIARYCONTAINMENT I1 STEEL O 3.FIBERGLASS ----0 6 INTERNALBLADDER <br /> ❑ 7 STEEL+INTERNALLIING ❑ 95.UNKNOWN ❑ 99.OTHER iSpecrfi-). 444 <br /> SECONDARY CONTAMIENT ❑ 1 STEEL3 FIBERGLASS ❑ 6.ECTERIORTffidBRA1g LINER ❑ 7 LACRFIED "5 <br /> ❑ 90 NONE 9395.144NDAN ❑99 OTHER(S dc). 443a <br /> OVERFILL PREVENTION ❑ 1 AUDIBLE B VISUAL ALARMS ❑ '_.BALL FLOAT QP3.FILL TUBE SHUT-OFF VALVE 4$2 <br /> 13 4.T.ANL),fMTSRE IMMIH0TSFOREtF[.TPTIONFROMO\TkFI.LPREIFNTTONE L7PNIENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1.SINGLE WALL Qj 2 DOUBLE WALL ❑ 99 OTIffiU 46.3 <br /> _SYSTEM T FE _ 1.PRESSURE El 2.GRAVITY _ Q 3 CONVFMTON.AL SU(M, ON ❑ 4.SAFE SUCTION f23 CC&,&36(.x3)1 438 <br /> PRIMARY CONTAINMENT -0 1 STEEL 4FIBERGLASS ❑ s F<R%lBl: ❑ 10 RIGID PLASTIC 464. <br /> 0 90 NONE 95.1"No"N 0 99 OTBERISpe it) a64 <br /> SECONDARY CONTAINMENT ❑ 1 STEEL �4 FIBERGLASS 0 S.FI.E':IBT F ❑ 10.RIGID PLASTIC 4616. <br /> ❑ 90 NONE 95.UNRNOAN ❑ 99 (qlm(Speedy). 46M. <br /> PIPING:TLIRBINE CONTWIMENT SUMP TYPE 0 1.SINGLE WALL Qt 2 DOUBLE WALL ❑ 90 NONE 4644. <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.S ERL 4.FIBERGLASS 0 10.RIGID PL.=c ❑ 90.NONE 0 99 OTffit(Speedy) J64e1: <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL $4 FIBERGLASS 0 10.RIGIDPL.ASTIC ❑ 90 NONE 0 99.OTEER(Speedy) 46tt1: <br /> VRPMMARYCONTAIWMENT ❑ 1 STEEL a4.FIBERGLASS 0 10 RIGIDPL.ASTIC ❑ 90.NONE 0 99.OTHER(Speedy) 1' <br /> VR SECONDARY CONTAINMENT E3.STEEL qk4 FIBERGLASS [1 10 RIGID PLASTIC 090.NONE 099.OTEER(Specdfi,)' 46yrj <br /> VENT PIPING TRANSITION SUMP TYPE [I1.SINGLE WALL M 2 DOUBLE WALL 090.NONE _ <br /> RIM PRIMARY CONTAINMENT 1p 1.Slffi. 0 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE 0 99.OTHEt(Specd)-) 4�j <br /> RISER SECONDARY CONTAINMENT 0 1.STEEL. R 4 FIBERGLASS 0 10 RIGID PLASTIC ❑ 90.NONE 0 99.OTBER(Specdt') M,�1 <br /> FILL COMPONENTS INSTALLED WL 1.SPILLBUCEFf W 3 STRUM PLATE'BOTTOMPROTECTOR 4.CONT.ADW ENT SUMP . . <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 0 1 SINGLE WALL �('�DOLBLEWALL 03_NODISPENSERS ❑ 90.,NONE_ <br /> CONSTRUCTION MATERIAL ❑ I.MUM 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) J46 <br /> 69�M1 <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION Ej 2 SAl9IFICLAL ANODES) ❑4 IMPRESSED LLIRRENT 6 ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify t this LTST system is compati le with the hazardous substance stored and that the information pro3ided herein is true, <br /> accurst , in m i n• h uirements. <br /> APPLICANT SIGNATURE DATE 1� 40 <br /> APPLICANT NAME(print) (�A� /',� f' 1 .APPLIC.ANf TITLE 4' <br /> UPCF UST-B Rev.(122007)-12 r!-:"' f 1;,' \\ w Oidoa.org <br />