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UNIFIED PROGRAM CONSOLIDATED FORM Ln <br /> UNDERGROUND STORAGE TANS' M1/� Z 15 <br /> OPERATING PERMIT APPLICATION-TANK INFO TION (one farm pa clsT> <br /> TYPE OF ACTION (Check one item mph,. For a OST clw xe or removal,complete m*this section mrd Sections L,IL,III,IV mrd LY helaul 430 <br /> '® L NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE Lj 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 1- DATE EMSTING UST DISCOVERED: 4306 <br /> I. FACILITY INFORMATION <br /> FACILITY ID»(Agem_r Use Onh9 <br /> 1_ <br /> BUSINESS NAME as Facdm A eorDAI-DoingBannua.4,/ 3 <br /> 4ta <br /> BUSINESS <br /> SITE ADDRESS 103 ` I <br /> 1 � � �Y' 1a <br /> II. TANK DESCRIPTION <br /> TANK ED 3 43'A�5TANK NLANUFACTL 433.�I/jF�R/ CONFIGURATION:THIS TANKIS 434 <br /> 0 1 <br /> 1 ✓Ifnl10�_ 1 W�D/ .ASTAND-ALONE ARTME camld9<auµp;<ruraM <br /> � �LVKKN .ONEINA cO2,8ARTMEKIID c?N[T wolrarmnn iu W<vmr. <br /> DATE UST SYSTEMA INSTALLED 4??- TANK C.-WgCITY IN GALLONS 436 NUMIBEIVF COMIPARTMENTS IN THE UNIT 4?- <br /> r<I 4W-C* 79)0 4& D b O c7 <br /> HL TANK USE AND CONTENTS <br /> TANK USE I. <br /> MOTOR VEIMCLE FUELING 13lb.MARINA FUELING ❑ I .AVLATION FUELING 4.193.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(memneuvm oa) 05.I3<ffiRGENCY GENERATOR FUEL IHSC;35+815(cy <br /> ❑ 6.OTHER GENERATOR REE ❑95.LIN7,"N_O?x_N ❑ 99 OTHER(Specif3'I 43% <br /> CONTENTS PETROLEUM ❑ Ia.REGULAR UNLEADED ❑ lc AH)CRADEUNLEADED 0 IN PREMIUMI(NLEADED 440. <br /> 6 i.DIESEL ❑ 5 IETFUEL ❑6.ANIATIONGAS <br /> 8.PETROLEUMBLEbDFUEL ❑9.OTHNRPHIROLHUM( - 1 440e. <br /> NON-PETROMI?M.D 7.USED OIL ❑ Ifl ETHANOL -----"- <br /> ❑ 1L OTBERNON-PETRcILELR1fS if%1 44a. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL I6 ,.DOUBLE WALL ❑ 95 1pNkWOWN 443 <br /> PRAiARY CONTAINMENT 14 L STEEL ❑ 3.FIBERGLASS (3 6 INTERNAL BLADDER 444. <br /> ❑ 7.STEELL+INTERNAL LE WG ❑ 95.LNIIFOWN ❑ 99.OTHER( '). <br /> SECONDARY CONTAINMENT ❑ 1 STEEL Q3.FIBERGLASS ❑ 6.E.RTERIORNEEMBRANELIN R ❑ 7 7ACXTED 445 <br /> ❑ 90 NONE ❑ 95 UNKNOWN ❑99 OTHER <br /> OVERFILL PREVENTION ❑ 1.AUDIBLE.L VISUAL ALARMS 2.BALL FLOAT �pr 3.FILL TUBE SHIT-DIFF\'PINE 4" <br /> 4.TANK MEETS REQUIREMENTS FOR EXMMON FROMOVERFILL PREVENTION E-UIPNENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL la 2 DOUBLE I ALL ❑_99 OTHER IN <br /> - " <br /> SY SII.M TYPE _ 1 PRESSURE GRAITTV ❑ 3 CONVENTIONAL SUCTION ❑,4SAFE SUCTION I'3 CCR¢�636(v 31 __. 438 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 4 EMERGE.US ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> .._ ❑ 90.NONE _. ..95.UNKNOWN p 99 OTBER(Speafy): 0640 <br /> SECONDARY CONTAINMENT ❑ 1STEEL <br /> 10 4 FIBERGLASS ❑ 8.3:r 3r3tmt>: ❑ ]O.RIGID PLASTIC 4wi <br /> ❑ 90 NOTA ❑ 95 coot 0 N p 99 OTHER(Spm) 4(W. <br /> PIFINGTLR RINE CONTAINMENT SUMP TYPE <br /> ❑ I SINGLE Ll'ALL '_DOUBLE R'.ALL ❑ 9(1.NONE Able <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1 STEEL RI 4 FIBERGLASS 0 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spccrfv I 46471 <br /> -- <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL �j 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spe 1 J6,0 <br /> VR PRIMARY CONTAINMENT ❑ I.STEQ. 10 4,FIBERGLASS ❑ IO RIGIDPLASTIC Q 90.NOFE ❑ 99.OTHERISpec3fil 1 <br /> VR SECONDARY CONTAINMENT 131.STEEL. R 4.FIBERGLASS ❑ 10AUGIDP,ASTIC ❑ 90.NONE ❑ 99 OTHER(Spec4fyl 4680 <br /> _...._._-- .-. ___.1.__. _ <br /> VENT PIPING TRANSITION SUMP TYPE ❑ .SINGLE WALL 9 2.DOUB-LE-WALL-0 90.NONE <br /> 3: RISFRPRIMARY WNT 4FTBERcMASS ❑ 10.RIGIDP.ASTIC ❑ 90.NONE ❑ 99.OTBER(Spm#l. ,&;p- <br /> 1 <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL. M 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NNE ❑ 99 OTHER(Sp.&y). 464[ <br /> FILL COMPONENTS INSTALLED X 1.SPILL BUCKET 3.STRA"ERP.ATE HOTTOMPtOTEr'1'-:-R--CH 4 CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 0_1„SINGLEWALL ._ )y'.DOUBLE 1l ALL ❑ 3N,_-DISPENSERS 09 NONE 4690 <br /> CONSTRUCTIONMATERIAL ❑ LSTEEL 4.FIBERGLASS ❑ 10.RIGID PASTIC ❑ 99.OTHER(Spmify) 464. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ '_.SACRiFICLU.AN<:IDE(S 1 ❑ 4 IMPRESSED CURRENT GF 6 ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I cerlifi'that this UST system is compatible with the hazardous substance stored and that the Information pro3ided herein is true, <br /> acava d in NR enm tan w" legal ruirements. <br /> APPLICANT SIGNATURE I Aq/ 4-n <br /> APPSCANT NAME(!®! ) 1 \ nL AMIICANT 711E.�0 <br /> UPCF UST-B Rev.(12flSW7)-I2 �J w .00idocs.arg <br />