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APR-7-2009 01:02P FROM: :12095332650 P.1 001196 UNIFO PICOGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (Ona Toms Pok usT) TYPE OF ACTION (Check one item only. For a UST closwe ar removal,complete only this section and Secttans 1,/1,Ill.IV and IX below) ; Q I.NEW PERMIT 3.RENEWAL PERMIT ❑ S.CHANOE OF INFORMATION 6.TEMPORARY UST CLOSURE 7 UST PERMANENT CLOSURE ON SITE8.UST OVAL DATE UST PURMANEN'I'LY CL OMIT. • DATE EXISTINO UST DISCOVERED: L FACII,TTY INFORMATION FACILITY ID A(Agemcy Usa Daly) 0USrNL48NAME me as Faculty Nama or DBA BurinEcs As) B spiu5 SCIE ADDRESS /j 03 CITY( ' 1a ll!/ 1 C.,- v / c �t`4' PI. TANK DESCRIPTION TANK 1D TANK MANUPACTURER 433. TANK CONFIGURATION:THIS TANK IS 174 `r r 4'\- S I.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIrr IDo m M -ATH U3 SYstbm INSTALLED TANK C TTti IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437, III, TANK USE AND CONTENTS TANK USE ❑ in.MOTOR VWIICLE FUPL LVO lh MARINA PUBL LNG ❑ Ia.AVIATION PUEUNG 3 ❑3.CHEMICAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE(Incada that Oil) ❑ S.0MMENCY OSNERATOR FUEL(ILSC L i-%(o)I ❑ 6.anlBlt OBNBLtATOR FUEL ❑ 95,UNKNOWN ❑ 99 OTHER ai : 439► CONTENTS PI3TRouum. [3 li REOUL.AR UNLEADED 0 to MIDORADA UNLEADED ]&PREMIUM UNLEADED 440. [y 3.DIEnL ❑S.11TT FUEL ❑6.AVIATION GAB _ ❑ B,PHTROI.HUM BLIND FUEL C]9,OTHER PITFROLIIUM Opectt3�'. -440L. . NON-PETROLEUM. 7.USED OIL -��10-ATNANOL 11,OMER NON-?M-ROLEUM 44M . TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL .DOUBLE WALL Q 93.UNKNOWN 441 PRIMARY CONTAINMENT .STEEL ❑ 3,NBP.ROL.A.S5 ❑ 6.INTERNAL BLADDER _--441. i -7.STflHI,4 LLINlNO ___ Q 95.UNKNOWN _O 99.OTHHR(Sp�vlly): - 44'- I SECONDARY CONTAINMENT X t MEL Q1,FIBERGLASS ❑6.M(TRRIOR M13MBRAN13 LINER ❑ 7 JACKETED 443, Q 90.NONE 93.UNKNOWN 99.OTHHR S 44_.- OVERFR,T,PREVENTION 1.AUDIBLE&"UAL ALARMS ❑ 2.BALI.PLOAT 3.PILL TUBE SHUT-OPP VALVA 452 4.TANK.BETS RE UIRPMHNIS POR EXfiMI'[ION PROM OVH ALL PRBVANTiON A UIPMENT V. PItO UCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION__ _ 1._SINGLE WALL 2.DOUBLAWALL 09.OTLIHit ' SYSTEM TYPE t.PRESSIURII 2.ORAVTTY 7,CONVRNTIONAL SUCTION 4.9APfl SUCTION 13 CCR 16 a 43a -- - --- I_-J_1603 PRIMARY CONTAINMENT 1.STEEL '4.FIBEROLASS [( R,M.AXIBIX ❑�10.RIGID PLASTIC ' ,0.NONE .UNKNOWN 99,OTHER{Spec 464. L SECONDARY CONTAINMEN7^ STEEL 4.FIBERGLASS 171,113GBLA RIOID PLASTIC 4644 ,.� v0.NONE 1.UNKNOWN ❑99.OTHBR S ): 4W PTPINO(IURBINE CONTAIN'ME'NT SUMP TYPE Irl.SINGLE WALL 2-DOUBLE WALL 90,NONE i/64 L VI. VENT VAPOR RNCO kki' AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I STM ❑4.FIBARGLASS ❑ I0.RIGID PLASTIC ❑90,NONB ❑ 99.OTHER(Spada): 4464. 66,1 VENT SECONDARY CONTAINMENT ❑ I STEEL ❑4.FIBERGLASS ❑ l0.RIGID PLASTIC _ X10.NONE ❑ 99.OTHER(Spw*): 4640 VR PRIMARY CONTAINMENI' ❑ 1.STBEL ❑ 4.FI88ROLASS ❑ 10.RIUID PLASM 90.NONE ❑99.OTtwil(5penify): 4 j VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.Rim PLASTIC.Tri".NONR ❑ 99.OTHER(st,-am: �4 VENT PIPING TRANSITION SUMP TYPE SINGLE WAIL ❑L DOUBLE WALL ., "00.NONII _ - RISER PRIMARY CONTAINMENT STEEL, ❑a.FIBERGLASS ❑ Io.Rram Pusrcc ❑9o,NONE ❑ 99.oTHnR(stwmb) RISER SECONDARY CONTAINMENT' ❑ I.STRRL ❑a.FIBERGLASS ❑ 10.RIOTD PLA3TTC 90.NONE ❑ 99.OTHER(3pe01ty): 464kJ FILL COMPONENTS INSTALLED SPELL BUCKETy~ 3.STRIKfEt PLATRIBOTTOM PRO TOR 4,CONTAINMENT SUMP P x"a W. UNDER DISPNSER CONTAINMENT CONSTRUCTION TYPE 1,$INOt B WALL ❑2.DOU0I,11 WALL ❑ 3.NO DIS PENSBRS ❑ 00.NONE 464+ CONSTRUCTION MATERIAL I r1a [] 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.UTHHR(specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 2.SACRIFICIAL ANOD S 4,IMPRESSED CURRBM' LSOLATION 44& IX APPLICANT SIGNATURE CERTIFICATION: 1 certify that Chit UST system is cmupatlble with the hazardous substance stored and tkat the Information provided hareta Is true, aeeyra sR 1 with legal mquirements. APPLICANTSIONATURE DATE + �' 70' APPLICANT NAME(prtnt) ' I APPLICANTTTTLE W�2 n. UPCR UST-B Rer.(13/ZB07) 413 www.wddoes.org v