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UNIFIED PROGRAM CONSOLIDATED FORMP,'/3 j F <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION con<r<t�F«usT) <br /> TYPE OF ACTION (Check one item o k Fora UST clwiwe or removal,complete mil v this section and Sections I,Ll,LLL,II:and LY below) 430 <br /> MIT' ❑ <br /> 1.NEW PER3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY-UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE 0 S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: Jam DATE EVSTING UST DISCOVERED: 430,. <br /> I. FACILITY INFORMATION <br /> FACRFCY-ID-(dgenc7,Use Onh•) a - - 1' <br /> BUSINESS NAME(Same as Faeilifi_Name orDB4-DoingBusmess.9s 3_ <br /> BUSINESS SITE ADDRESS 10i CITY 104 <br /> II. TANK DESCRIPTION <br /> TANS ID= 1 1" TANK M.ANUFA 433. TANG CONFIGURATION:THIS T_ANI:IS 434. <br /> rn9�E1taL GSD/ IS I .ASTANDALOICTAHI: c®p m�v�•rwmm <br /> ? ONE INA COMPARTMENTED CTAT aaul.4woam We wnt. <br /> DATE US_;SYSTEM INSTALLED$ 415 TANK CAP.ACiEY IINNGALLONS J36. NI1MffiER OF COMB'ARTMJENTS IN THE UNIT 43' <br /> f>7 O G <br /> III. TANK USE AND CONTENTS <br /> TANK CASE jY Is.MOTOR VEHICLE FUELING ❑ Ib MARINA FUELING ❑ Ie.AITATIONFUELiNG 439. <br /> ❑3.CHl MLCAL PRODUCT STORAGE ❑ 4.HAZARDOUSWASTE0oohdwUedOh) ❑ 5.EMERGENCY-GEhffitATORFUEL[HSC§25!815(01 <br /> ❑ 6.OTHER GENERATORFUE. ❑95.UNENOWN ❑ 99 OTBER(Sp..01. 43% <br /> CONTENTS PETR(LEUM: 10 Ia REGULAR L1ILILADED ❑ Ic.MIDGRADEUNLEADED ❑ It, D <br /> FRENITUMINLEADJ46. <br /> 3.DIESEL ❑ 5.JET FUEL ❑ 6.A)T.ATIONG.AS <br /> ❑ S.PETROLEUMPLENDFUEL ❑ 9.OTEERPE7ROLEUM(s - )- .4400 <br /> NON-PETROLELAi:❑ 7.USED OIL ❑ 10.ETRANOL <br /> ❑ 11OTHERNON-PETROLEUMS(S ,.N) <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2 DOUBLE WALL ❑ 95.ITENOWN ----------- 443. <br /> PRIMARY CONT.ALNMENT gr 1.STEEL [I 3 FBERGLASS [16.INTERN,AL BLADDER Jbt. <br /> ❑ 7STEEL.+INTERNALLINING ❑ 91 LNINOWN ❑ 99 OTHER(SPItV- <br /> SECONDARY CONTAINMENT ❑ 1 STEEL. I§3.FIBERGLASS ❑ 6.0,11 RIC IA MBR.ANE LINER ❑ 7 J.AC"TED a;s. <br /> ❑ 90.NONE ❑ 95NLNOWN ❑99.OTBEt(Specifyl. A4Si _ <br /> OVERFI.I.PREVENTION ❑ 1.AUDIBLEB1TSUA1..AL.ARE19 ❑ BALLFLOAT Z 3 FILL TUBE SHCIT-0FF VALVE 452 <br /> 4.TANS MEETS RE(L7RELIENTS FOR E%EMPfIOi FROM07'ERFILL PL'VTNTTONE UI1,1ENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> THING CONSTRUCTION ❑ 1 SINGLE WALL IS 2 DIASLE"_ALL ❑ 99 OTHER4M <br /> SYSTEMTYPE .__Alp PRESSURE ❑ _.GRAYTTY ❑ 3 CONVNION.AL SUCTION ❑_4_SAFESUMON[? 9M 6361aN3)] 458. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 1 4.FHBERGL.A.SS ❑ S.FIZUBLE ❑ 10.RIGID PLASTIC 461. <br /> ❑ 90 NONE ❑95.114NOUN ❑ 99.OTHER(Spccdy): _ <br /> SECONDARY CONTAINAIENT ❑ 1.STEEL JR 4.FIBERGLASS ❑ e.FLE'IB4 E ❑ 10.RIGID PLASTIC 4Mb <br /> ❑ 90.NONE ❑ 95 UNWOWN ❑ 99.OrHER(SwA,), ec4a- <br /> PLPNG:TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL W_.DOUBLE WALL ❑ 90.NONE J6u <br /> VI. VENT,VAPOR RECOVERY <br /> y((VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1 STEEL (N4.FIBERGL.ASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 990TIM(SPrody) J6k1 <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL 8'4.FIBERGLASS ❑ 10.RIGID PLPMsm ❑ 90 NONE ❑ 99 OTBER(Specdy). 46111 <br /> VR PRIMARY CONTAINMENT _❑ I STEEL a 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPOC41 <br /> VR SECONDARY CONTAINMENT' ❑ 1 STET1 94.FIBERGLASS ❑ 10.RIGID PLASTIC 0 9.NONE ❑99.OTHER(SPcclfyl. 46ad <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL IF ^_DOUBLE WALL ❑ 90 NONE <br /> RISER RIMARYE)D21TATNI�NT.. L.,. -- �4.FIBERGLASS 1310 RIGIDP..ASTIC 11 90 NONE ❑ 99.OTHER(spMoyr. 4J61._ <br /> RISER SECONDARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS [1 10 RIGIDP..AsnC [190.NONE ❑ 99 OTHER(Sp>edyT <br /> FILL.COMPONENTS INSTALLED jg I SPILL BUCSET 3.STRWERPLATEiBOITOMPROTECTOR 19 4 CONT.AIIEIENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1 SINGLE WALL DATBLEIVALL ❑ 3 NODISPENSERS [:1.90 N<SM 46% <br /> CONSTRUCTION MATERIAL. ❑ L STBEL Xl 4.FIBERGLASS ❑ l0 RIGIDPLASTIC ❑ 99.OTHER(Specify) 469e <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION :.SACRIFICIAL.ANODFFAS I ❑ 4 AIPRESSII)CITRRENT P5 6 ISOLATE N 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify' t this UST syste is compatible oil, the hazardous substance stored and that the mformafion provided herein is true, <br /> acatra fu with legal Ireutuirements. /^� <br /> APPLICANT SIGNATURE DATE C)D QcJ %1� Aro. <br /> APPLICANT NAME(pmt) ' 491. APPLICANT TITLE llll 4 <br /> UPCF UST-B Rev.(11241//)-f2 wwrvrwido org <br />