BILLING 2003 - 2009 - Laserfiche WebLink

Home Browse Search

" A UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II.III,IV,and IX below) OU ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) D - 1 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. ARP mwimPOLT ( UNION 76) BUSINESS SITE ADDRESS 163. CITY 1o4 2 5 5 S . P�r� l" as o r� F�Flss TR R G II. TANK DESCRIPTION TANK ID# q 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. x e S ❑❑ 2.AOI E IN STAND-ALONE RTMTMENTED UNIT COMPLas °�`��, mens in the wh. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. Iq 3 0 000 1ONE III. TANK USE AND CONTENTS TANK USE ® Is.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ 1c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inch da Used Oiq ❑ 5.EMERGENCY GENERATOR FUEL[HSC f25231.5(c)] ❑ 6.OTHER GENERATOR FUEL_ ❑ 95.UNKNOWN _ ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ® Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED iuo ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _ [19.PETROLEUM BLEND FUEL _❑ 9.OTHER PETROLEUM(Specify): 440a. NON-PETROLEUM:❑ 7.USED 011. ❑ 10.ETHANOL ❑ I I.OTHER NON PETROLFUM 440e. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL t5 2.DOUBLE WALL ❑ 95.UNKNOWN 441 PRIMARY CONTAINMENT ❑ 1.STEEL 01 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER ify): 444a. SECONDARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN (]99.OTHER(Specify): 4454L OVERFILL PREVENTION ($ L AUDIBLE do VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E MM04T V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION _-Q 1.SINGLE WALL C1 2-DOUBLE WALL_ 0 99 OTHER _ ____�_ 460 SYSTEM TYPE �® 1_PRESSURE ❑ 2.GRAVITY (] 3.CONVENTIONAL SUCTION 0-4.SAFE SUCTION[23 CCR¢x63e,X3fl 439 PRIMARY CONTAINMENT 0 I.STEEL ❑ a.FLEXIBLE ❑ 10.RIGID PLASTIC 4� ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464` _ SECONDARY CONTAINMENT ❑ 1.STEEL 0 a.FQiE RGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b, ❑ 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Specify): 464c. P�]NC,/TURBINFi CONTAINMENT SUMP TYPE ej 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ®4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1. VENT SECONDARY CONTAINMENT ❑ 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC �90.NONE ❑ 99.OTHER(Specify): 40'/' _ _ ,ban. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE E399.OTHER(Specify): 4"9.VR SECONDARY CONTAINMENT [31.STEEL ❑ 4.FIBERGLASS [310.RIGID PLASTIC C9 90.NONE ❑ 99.OTHER(SpecifY)- bj VENT PIPING TRANSITION SUMP TYPE [31.SINGLE WALL E32.DOUBLE WALL CW 90.NONE - 464i. RISER PRIMARY CONTAINMENT IN I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9o.NONE ❑ 99.OTHER(specify): RISER SECONDARY CONTAINMENT ❑ I.STEEL Ja 4.FIBERGLASS ❑ 10.RIGID PLASTIC [3 90.NON: ❑ 99.OTHER(SpecifY): 4664k1. FILL COMPONENTS INSTALLED W 1$( I.SPILL BUCKET ® 3.STRIKER PLATFJBOTTOM PROTECTOR 9 4.CONTAINMENT SUMP 431 a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE! _ ® 1.SINGLE WALL _ ❑ 2.DOUBLE WALL C1 3.NO DISPENSERS ❑ 90.NONE _ 469a CONSTRUCTION MATERIAL [31.STEEL ® 4.FIBERGLASS [310.RIGIDPLASTIC 1399.OTHER(Specify) 446ya VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION at• 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored and that the Information provided bejdn is true, accurate,and In full com Liance with legal requirements. APPLICANT SIGNATURE DATE 1 L2002azo. APPLICANT NAME(print) 471 APPLICANT TITLE 4n GiRATEL TRGASURE UPCF IJST-B Rev.(12/2007)-112 www.unidocs.org