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APR-7-2009 01:03P FROM: T 2095332650 P.2 001196 Cp e UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERNUT APPLICATION-TANKPMORMATION (One form v«umT TYPE OF ACTION (CA ack oue Ilam axly For a U c orure or nen 1 cava I[] I.NEW PmtM7T ' 3.RENEWAL PERMIT=;=only smctlonandSecstov. I,it,A O 1Y and 6.TEMPORARY UST CLOSURES.CHANGE OF INFORMATION 7 UST PERMANENT§aQPR13 ON B1T8 8.UST REMOVAL DATE UST PERMANENTLY CLOSED DATE EXISTING UST DISCOVERED: 4 r.YA P[tOgMAVON PACILfi'Y ID N(4-may rd nly) 1 11USINESS NAME me a F lty Mama a DBA g bWafl-As) J- G th - ky 1z� 14- 8 9fyFS 3f[EADDRESS .' v S U. TANK DOC ItIPT 3 N TANK[D N TANK MANUFACTURER lr�ss TANK CONFIGURATION THIS TANK 18 434. / i� u r f (�1.A STAND-ALONE TANK owpip pr�ry V /V (� UNH 1 P 6n Rr uek. UA78 UST SY TLM INSTALLED TANK CAP IN OALLO S 4J• NUMBER OF COMPARTMENTS IN THE UNIT 417. III. TANK USE AND CONTENTS TANK USE Q Ie.MOTOR VEHICLE FUELING g Ib.MARINA PUHLINO ❑ lo.AVIATION FUHLIUO 459 ❑ J.CHEMICAL.PRODUCT STORAGR ❑ 4.HAZARDOUS WAh-M(Dr:bd.r tl.m OtO ❑ J.OMRROI.NCV ORNH.RATOR FUEL V={2S7e;St.); _ Q 6.OTHER GENERATOR FURL 119!.UNKNOWN _ ❑ 99.crMER 434. r CONfEN'TS PHTROLHUM. [� 1�RAOULAR UKLIW690 C3 to.MIDORADB UNLEADQD [J Ib.PRIIMIUM UNLEADED 4a, 3.DJESBL C, I.JET PURL ❑ 6.AVIATION OAS (] R.PETROLEUM BLEND Ftt1RL ❑ P.OTHER P6'IROL13UM(Speoiiy): 44Oa. NON-PM-R0LEUM.rf 7.USED OIL 10•ETHANOL 11.07NRR NON-PBLROLBUM MOs IV TmwCf?NSaI MON TYPE OF TANK I.SINGLE WAIL JE2,DOUBLE WALL ? 5.UNKNOWN 4 PRIMARY CONTAINMENT 1.STBBI, 3.PmmmA98 6.INRIRNAL BLADDER +44. __ _ 7.SIBEL.+THMNALLINING C393.UNO NKWN Q99.OTHER(spa4tll*): 44U SECONDARY CONTAINMENT (Q 1.STEEL .FIBERGLASS C36.EICTTB M MEMBRANE UNHR E37.JACKHTHD 44s 90.NONE 93,UNKNOWN 99.OTHE1 445a OVERFILL PREVENTION Cl 1.AUDIBLE&VISUAL ALARMS ❑2,BALL FLOAT Arj.FILL TUBE SHUT-OFP VALVE 4.TANK MEM R MHNM FOR(3XEMPTION FROM OVERFIL,ABVHKrION wulpmaw V. PRODU /'WASTE HPING CONSTRUCTION PIPING CONSTRUCTION 0 1.DINGLE WALL 2.DOUBLE WALL, g9.OTHER 4N, SYSTEM TYPE PRESSURE GRAVITY r3_CONVENTIONALSUCTION_a,4_SAFE 9t)CI!ON lli0M a>ai)f)i_- ase. PRIMARY CONTAINMENT [] 1.MEL F19ERGI.AM ❑S.PLt)X18LH ❑ 1O.RIGID PLASTIC 444 ❑ 00.NONE ❑95.UNKNOWN ❑ 464► SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBBRGLAS3 ❑R.PLmus [] M RIGID PLWMC 4446 Q0.NONE Cl 93.UNKNOWN Cl 99.OTMR(SpnItYX 464. PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLB WALL Q 2.DOUBLE WALL 90,NONE 464A� V1. VENT, SAP®It Ri COV}IItY ANO IMER i FTLL PWH PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1 STHHL In 4.P101IRGLASS ❑ 10.RIGID PLASTIC Q M.NONE ❑ 99.OTtIER(Spalfy). ,*No VENT SECONDARY CONTAINNILNT ❑ 1 STEEL ❑4.FIBBROLL4S [1 40.RIGID PLASTIC 90.NONE Cl 99.OTHER(spew: 4440 VR PRIMARY CONTAINMENT ❑ I,STEEL ❑ 4.FIBERGLASS ❑ 10.RIO1D PLASTIC 90.NONE C] 99.OTHER(Speclb): VR SECONDARY CONTAINMENT L3 1.STEEL, Cl 4.FIBERGLASS d lo.RKIID PLASTIC 90.NONB~❑99.OTMiR(Bosdl*): 46*1 VENT PlPINO TRANSITION SUMP TYPF. ❑ i StNQtB WALL ❑2 DOUBLE WALL 90.NONE T RISER PRIMARY CONTAINMENT 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PI.AB'TIC ❑ 90.NONH Cl 99.OTHER(Spsolly): RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑4.FIq GLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHM(SI1edfy). 4 4m 1 FILL COMPONENT'S IDlSTALLEW - 1.SPILL BUCKET r 3.STRIKIM IKATWBOTTOM PROTECTOR Q 4.CONTAINMENT SUMP a•a VICE L"ZRDISPEN5ER CONTAINMEIff M CONSTRUCTION TYPE1 SINGLE WAIL 2•DOURLS WALL 3.NO D SPHNSERE 13 go.NONE CONSTRUCTION MATERIALsTHIlL ❑4.FIBERGIAss ❑ to.mein PIASITC ❑99.OTHER(spew*) VW. sqo ►s1014I'�.4T�MON STEEL COMPONENT PRO 1 EC7lON 1,SAGUPi AL ANO 9 4',IMPRESSED CURRENT 6.ISOLA tort 48. I. APPLICANT SIGNATM CERT11FICATION:1 eertffy that" UST gRtem is compUbie with On lmrdm nbItenm dored and that fire Infomatbe provided bmtn is true, au:cur4lla and Ir feU cea lace wttM el ul !+ APPLICANT SCONATURE � DATE APPLICANT NAME(print) 01 1' 1APPLICANTTYTLE v UPCF UST--Rev.01rion 1/I www.waldomorp