BILLING 2014 - 2015 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK r OPERATING PERMIT APPLICATION - TANK INFORMATION TYPE OF ACTION (Check one item only. For an UST pcmauent closure or removal, complete only this section and Sections I, IL III, IV, and IX below) 430 ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFO 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE El 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430s DATE EXISTING UST DISCOVERED: 430In I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ t BUSS NAME (Sams es FACILITY NAME or DBA-Doing Business As) 3 BUSIKESSSITE ADDRESS 103 CITY 104 LA m II. TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFlGURATION: TRIS TANK IS 434 TA alb I S o 3 �DaQT^ '�`� i^ 2.ONE W A-ALONETANK ❑ 2ifto M A COMPARTMENTED III9ff . aeon (urud� mNeumt DATE, UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLO °>6 NUMBER OF COMP TMENTS IN THE UNIT 437 III. TANK USE AND CONTENTS TANK USE aria. MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELiNG ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oa) ❑ 5. EMERGENCY GENERATOR FUEL [HSC 1252815(01 ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ Is REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ It. PREMIUM UNLEADED 410 l.9. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ S. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440s NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL I I.OTHER NON-PETROLEUMS 410In rV. TANK CONSTRUCTION 95. UNKNOWN 4 TYPE OF TANKq❑ SINGLE WALL 2. DOUBLE WALL [1 95. �l1. PRIMARY CONTAINMENT J_k. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 IM ❑ 7. STEEL +INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): "Ia SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LEER n ❑ 7. JACKETED a5 ❑ 90. NONE ❑ 95. UNKNOWN .OTHER (S ): 7 445a OVERFILL PREVENTION I. AUDILE 8 VISUAL ALARMS 2. BALL FLOAT 3. FILL "TUBE SHUT-OFF VALVE 452 ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT - V. PRODUCT/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE-WALLED 291 DOUBLE-WALLED [199. OTHER 469 SYSTEM TYPE .PRESSURE ❑ 2. GRAVITY 3. CONVENTIONAL SUCTION 4. SAFE SUCTION CCR §2636(m)(3)] 458 PRIMARY CONTAINMENT L STEEL �4. FIBERGLASS ❑ 8. FLEXIBLE ❑ %RIGID PLASTIC 464 ❑ %.NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Spccify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL W. FIBERGLASS 8. FLEXIBLE ❑ 10. RIGID PLASTIC 46ab ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): /64c PIPINGrrURB1NE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL 0 90. NONE 4644 VL VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Lj 1. STEEL Qr4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 99. OTHER (Specify) 464e 4641 VQlf SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC JR 90. NONE 99.OTHER (Specify) 4Nf 4NFl VR PRIMARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ 10. RIGH PLASTIC Q 90. NONE 99. OTHER (Specify) 4649 464 1 VR SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC .NONE Q 99. OTHER (Specify) VENT PIPING TRANSTIION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL 90. NONE RISER PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS 10.RIGHPLASTIC 90. NONE 99. OTHER (Specify) RISER SECONDARY CONTAINMENT . STEEL 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 14r. FILL COMPONENTS INSTALLED 1. SPILL BUCKET . STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT (UDC)CONSTRUCTION TYPE . SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS . RIGID PLASTIC ❑ 99. OTHER (S ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448_ III. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the b"ardous substance stored and that the information provided herein is true, accurate, and is full with legal re uirenreots. APPLIC�b fREM NAT DATE �D aro. /' APPLICANT NAPM) °71' APPLICANT 4R UPCF UST -13 -1/2 Rev. (12/2007)