BILLING - Laserfiche WebLink

Home Browse Search

FE 23(e O �} l /1Gt-) d4 &. 5Zd 8'20 % �3 UNIFIED PROGRAM CONSOLIDATED FORM �� oAA UNDERGROUND STORAGE TANK 3�hy ✓//� OPERATING PERMIT APPLICATION-TANK INFORMATION(One fo�p Us TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,Bl,IV,and oW� ❑ 1.NEW PERMIT [13.RENEWAL PERMIT El 5.CHANGE OF INFORMATION :33 [:1h.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE ® 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: mos DATE EXISTING UST DISCOVERED: 410b I. FACILITY INFORMATION FACILITY ID#(Agency Use 0*) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 W.L.Hams Trust BUSINESS SITE ADDRESS 103 CITY IN 16051 E.Mello Ave I Ri on H.TANKDESCRIPTION TANK ID# NA 432 TANK MANUFACTURER 433 TAMC CONFIGURATION: THIS TANK IS 4M Unknown ®1.ASTAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Cam lee our fur oath mm min 11e we. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 43 -1977 2,250 1 IM TANK USE AND CONTENTS TANKUSE ❑ Ia.MOTOR VEMCLEFUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING. 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTEpwlwa u4ee On) ❑ 5.EMERGENCY GENERATOR FUEL[nse psui.5(c)j ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNICNOWN ® 99,OTHER(Specify): Farm Tank 43% CONTENTS PETROLEUM. ® Ia.REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ❑ It.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.CITIES PETROLEUM (specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 0 11.OTHER NON-PETROLEUM e : a4ab IV. TANK CONSTRUCTION TYPE OF TANK ® L SINGLE WALL ❑ 2.DOABLE WALL ❑ 95.UNKNOWN a3 PRIMARY CONTAINMENT 29 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNALBLADDER 444 ❑ 7,STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHERS ): 4444 SECONDARY CONTAINMENT ❑ 1.STEEL [13.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ® 90.NONE ❑ 95.UNKNOWN ❑99.QTHER i 4454 OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALI,FLOAT ❑ 3.1`II.1.TUBE SHUT-OFF VALVE. 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROMOVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ®1.SINGLE-WALLED ❑2.DOUBL&WALLED [199.OTMR 460 SYSTEM TYPE ❑ L PRESSURE ❑ 2.GRAVITY V9 3.CONVENTIONAL SUCTION ❑ 4-.S SUCTION v CCR§2636(. ) 452 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS miry): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b IR 90.NONE ❑ 95.UNKNOWN ❑ 99.MINER S ): 464 PI'TNG(NRBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ T UBLEWAW. ® 90.NONE Orad VT.VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE. 0 99.OTHER(Specify) 464e VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 4640 VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ® 90.NOME Ij 99.OTHER(Specify) 4648 4MR1 VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHFA(Specify) 4641, VENT PIPING TRANSITION SUMP TYPE 1.SINOLE WALL ❑ 2.DOUBLE WALL 90.NONE 96 h14w1. RISER PRIMARY CONTADM ENT ❑ 1.STEEL L1 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 90.NONE 99.OTHFR(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE 99.OTHER(Specify) 464k FILL COMPONENTS INSTAI.LEU ❑ 1.SPILL BUCKET ❑ 3 STRIKER PLATEMOTTOM PROTECTOR 4.CONTAINMENT SUMP 4se VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUC11014 TYPE ❑ I.SINGLE WAI A. ❑ 2.DOUBLE.WALL IH 3,NO DISPENSERS ® 90.NONE 469. CONSTRUCTION MATERIA, ❑ ].STEEL ❑ 4,FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 46ffx VHL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 446. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the ha tardous substance stared and that the Information provided herein is true,accurate, and in full cam liaill If/Al reaAements. APPLICANT SIGNATURE DATE 3 zo. � 43a APPLICANT NAME(print) / 411- APPLICANT TITLE •F / 472, Y UPCF UST-111•U2 Rev.(12@607)