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UNIFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form Per UST) <br /> TYPE OF ACTION (Checkone nein cnht For a LIST closur a or removal,complete onh'rbrs sernon and Secnmu h II,III,IT*,and R'belong 430 <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION <br /> 6.TEK WORARY UST CLOSURE 0 7.LTST PERhLANEM CLOSL7iE ON SITE El 8.UST REMOVAL <br /> DATE LTST PERMANENTLY CLOSED: 131a DATE F_MSTING UST DISCOVERED: 43M <br /> L FACILITY INFORMATION <br /> FACILITY ID=C.germ'Use 0nh9 I I R I I - 1' <br /> BUSINESS NAME(Same os Faeili��Same o'vG 'IgBusmyy99s. 3 <br /> /yI r Ci- vonv- <br /> BUSINESS SITE ADDRESS 103 CM � 104/6 <br /> II. TANK DESCRIPTION <br /> TAW ID- 432 TANT:IsLAN LTFACTC7RER 433 TANr CONFIGURATION:THIS TANK IS 434 <br /> 3 I ASTAHIIALONETAN6 Cmidet .pie form <br /> o5155 e-) 19&Abe- J 1_tP1At 2 ONEINA CO18ART1.1ENTIDLTNTf wwP�a ,aW aaa <br /> DATE LTST SYSTEM INSTALLED 435. T.ANA C.AP.A(WY IN GALLONS 436 1 NUMBEROF COMPARTMENTS IN THE ITN1T 43- <br /> e oa 'r, 00 <br /> M. TANK USE AND CONTENTS <br /> TANK USE 9la.MOTOR VE CLE FUELING 01b.MARINAFUEI.ING 0lc.AVLA IONFUELING 439 <br /> 3.C11MCAL PRODUCT STORAGE (34.HAZARDOUS WASTE 4.1nda UwdM) 05 EIAERGHNCYGENERaTORFUEL JWC f25:B15(c)] <br /> 0 6.OTBERGENERATORFUE. 0 95.UNJT NOIN 0 99.OTHER(Specify) 43% <br /> CONTENTS PETROLEUbf 0 la.REGULARLTNLEADED 0 le h1IDGRADEUNLEADED 0 Ib.PRMffUblUNLEADED 440. <br /> 19 3.DIESEL 0 5 )ETFLTEL 0 6.ANIATIONGAS <br /> 0 8_PETBOLEUMBLEND RTEI 0 9 0THERPETROLELIDI(9 ) <br /> NON-PETROLEUM.0 7 USED OIL 0 10 ETHANOL ------- <br /> 13 11.0THERN0N-PETR0LELTMIS d 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TAI-K 0 1 SINGLE WALL ®2.DOUBLE WALL 0 95 UNI.N(A N 443_ <br /> PRBdARY CONTAINMENT I STEEL. 0 3.FIBERGLASS 0 6 MTR'RNAL BLADDER da4a 444 <br /> 7.STEEL+INTERNAL LINING ❑ 95 LTNLNOAN 0 99 OTRERISpc:ffy. <br /> SECONDARY CONTAINMENT ❑ I STEEL, i FIBERGLASS 0 6 L%ER[ORMRfBRANEL]NER 0 7.).ACITfED 445. <br /> ❑ 90.NONE 95 UNINOtiN 099 OTHER(S ). 44A <br /> OVERFILL PREI'ENTION 0 I.AUDIBLE&YTSUAL ALARMS ❑ 2.BALL FLOAT (b3.FILL TUBE SHUT-OFF VALVE 41-. <br /> 4.TANSl.]EETSRE tMMENTSFOREIMWHI:1 NFRO1.f OlMMUPREAENIIONH L-MENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 13 1.SINGLE PALL 1&2.DOUBLE WALL 0 99.OTHER <br /> SYSTEMTYPE [a-I PRESSURE 0 2 GRAATTY ❑ i CONAENTIONAL SUCTION 0 4SAFE SUCTION x3tCrt C636wX3 458. <br /> PMI-kRY CONTAINMENT 0 1 STEEL a 4.FIBERGLASS 0 8 FLE%R3 n 0 10.RIGID PLASTIC 464 <br /> 0 90 NONE 0 95 IM NO11N 0 99 OTHER(Speclfiq asaa <br /> SECONDARY CONTAINMENT ❑ 1 STEEL Nt 4 FIBERGLASS 0 8 FLEUBLE 0 16 RIGIDPASTIC <br /> 0 90 NONE 0 95 LTNLTIOPN 0 99 OTHER(Specit') <br /> PIPIN(3,TURHINE CONTARdhBNT SUMP TYPE 1 SINGLEWALL 3W 2 DOUBLE WALL 90.NONE 464a. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.SIiEI. 4.FIBERGLASS 0 10.RiGIDFLASRC ❑ 90 NONE [1 99 OTHER iSpecTF'1 46te1 <br /> VENT SECONDARY CONTAINMENT ❑ 1STEE. 4FIBERGLASS 010.RIGID PLASTIC 090 NONE 099.OTEER iSpe&, ,gyp <br /> VR PRIMARY CONTAINMENT OI.STEEL 04 FIBERGLASS 010.RIGID PLASTIC _090 NONE 099.OTHERISpeufv) 4 1 <br /> VR SECONDARY CONTAINMENT 0 1 STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90 NONE 0 99.OTEER ISp uh) 46463. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL Sr-D-TTBLE WALL 0 90.NONE <br /> jgr- <br /> RISER PRIMARY CONTAINMENT %ISTEEL 0 4.FIBERGLASS 0 10 RIGIDPLASHC 0 90 NONE 0 99.OTEER(Speciv) <br /> RISER SECONDARY CONTAINMENT 0 1 STEEL. B 4 FIBERGLASS 0 10.RIGID PLASTIC'. 0 90 NONE 0 99 OTHER(Specth) <br /> FILL COMPONENTS INSTALLED Ca I SPILL BUQ.TT i STRIKER PLATE BOTTOMPROTECTOR 4 COFITARZIENTSU1,4P .lac <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE p_I_SINGLE P:ALL M-'-DOUBLEAYALL 0 3 N��DISPENSERS___ 0 90,NOFIE_______ 46% <br /> CONSTRUCTION MATERIAL 01.STEE. 4.FIBERGLASS 010.RIGID PLASTIC 099.OTHER(Spedi ) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2 SACRIFI'LAL ANODES) 04 AIPRESSED CLTJUNT6ISOI..ATION 448 <br /> IX. APPLICANT SIGNATURE 91 <br /> CERTIFICATION: I certifvtha this UST wstem is compatible with the hazardous substance stored and that the information pro3ided herein is true, <br /> accurst n in full ompliance witb leal requirements. <br /> APPLICANT SIGNATURE DATE V 1 4-0 <br /> APPLICANT NAME(print) LOCK4_t APPLICANT TITLE4 ' <br /> UPCF UST-B Rev.(1212067)-12 www.uuidmmorg <br />