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, <br /> - <br /> � <br /> | <br /> � <br /> ' <br /> � <br /> ' <br /> | ' <br /> ! <br /> i <br /> | <br /> ' <br /> � <br /> � <br /> UNIHED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (0-f-p-UST) <br /> lT_:_._:_., '.-I <br /> YPEOFACTION (Chack one item only. For a USTd"ure or remova4 compkie only&4 section and Sections 1,14 LT.ly andiXbd-) <br /> I.NEW PERMIT [1 3.RENEwAL PERMIT 5-CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSM Q 7.UST PERMANENT CLOSM ON S]TE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED- 43ft 1 DATE ExwnNG LIST DT"VERFX� 430b, <br /> FACILITY II)#(Afflmcy Use 0*) <br /> BUSINESS NAME(Same as Facft N.or DBA-,DoinX Business As), 3. <br /> Busmm SITE ADDRESS 101 104. <br /> 434. <br /> TANK MANUFACTURER 431 TANK CONFIGURATION-THISTANK IS <br /> DATE=SYSTEM RWALJM TAWCAPAWTIN 436, NLWER OF COMPARTMOM IN THE UNIT 43T <br /> 61 <br /> 439. <br /> TANK U'Sf Van=FLELING 0 lb.MARINA FUELING ic.AwAnoN FuELING <br /> 5.EMERGENCY GENERATOR FUEL RW"I-X01 <br /> 3,CHEMICAL PRODUCr STORAGE Cl 4.HAZARDOUS WASTE O-W-L"d Oil) 439& <br /> [1 6.OTHER GENERATOR FUEL [1 95.UNKNOWN El 99.OTHER(Spac6j, <br /> -66NT-WM PETROLEUM: II_REGULAR UNLEADED 0 ir-MIDGRADE UNLEADED D ib.PREmrUmU9LEADED 4W <br /> 3,DIESEL D S.JET RJEL [1 6.AVIAT10N GAS 440. <br /> 8.PETROLEUM BLEND FUEL [3 9-OTHER TROLEUM PK&Y). <br /> NON-PE-TROLEUM.-El 7-USED OIL U 10.ETHANOL 440b. <br /> 11.Glum NON-PETROLEUM§_S�: <br /> TYPEOFTANK 1.SWGLE WALL I DOUBLE WALL L]95.UNKNOWN <br /> PRIMARY CONTAINMENT 1.STEEL 3.FIBERGLASS 6.INTERNAL BLADDER 444. 444. <br /> 7.STEEL+INTERNAL LINING 95.UNKNOWN El"-OTHER(SP <br /> SECONDARYCONrADIMENT E] I-STEEL El 3.FIBERGLASS El 6.EXTERIOR MEMB 445. <br /> 0 90.NONE [1 95.UNRNOWN IQ 99.OTHER(Spodfft, <br /> -ILL TUBE SHUT-OFF VALVE 45L <br /> OVERFELL pREVENIJON 1.AUDIBLE&VISUAL ALARMS 112-BALL FLOAT .43.1 <br /> 1D 4.TANK MEETS REQUIRBA-ERM FOR EXEMPTION FROM OVERFILL MEVRMON <br /> 12 <br /> ka <br /> PIPING CONSMUCMN. U 1.SINGLE WALL op 2.DOUBLE WALL 6�9.OTHM 45L <br /> AL SUCTION 0 4.SAFE SLCnM 123 CCR P6MW)l <br /> SYSTEM TYPE I.PRESSURE 0 2.GRAVITY 0 3.CONVENTION CTION y 4 4&4- <br /> PREMARY CONTAWWla I.STEEL [1 4.FIBERGLASS Ef S.FLEMBLE U 10.RIGID PLASM 464& <br /> 90.NONE 13 95.UNKNOWN 0 99-OTHER(Specify- <br /> CONTADUAENT IF-"4ZIiEI- [14.FIBERGLASS W a.FLEXIBLE t .RIGID PLASTIC 464c- 46V. <br /> 13 90.NOW 95.UNKNOWN 19 99.OTHER(Sl)ccif�)-- rc INNA fAZK <br /> TYPE L SINGLE WALL 2-DOUBLE WALL [I 90.'NOKE <br /> VENT PROAARY CONTAR4AENT I.STEEL W 4.FIBMGLASS 0 10-MID PLASM go.NONE 0 OTHER.(Spwify). 464.1. <br /> VFyrSEWNDARy TAINMENT J5 1.STEEL 0 4.FIBERGLASS 0 10-RIGID PLASTIC go.Now 13 99 OTHER V-pa*), 464fl. <br /> VR rRDAARY CONTAINMENT J4 1.STEEL Ll 4.FIBERGLASS El 10.RIGID PLASTIC 13 90.NONE 0 99-OTHER N='fy): <br /> VR SECONDARY 0C)NTAROAENT 1.STEEL 0 4.FIBERGLASS 11 10.RIGID PLASTIC 12 90.NONE 0 99.OTHER rV-fY): 464hl. <br /> - 464i- <br /> VENT PEPING TRANSMION SUMP TYPE 1.SINGLE WALL [1 2.DOUBLE WALL Q 90.NONE 4W <br /> RISER PREMARY CONTARMENT 1.STEEL 0 kFIBEILGI ASg 10.RIGID PLASTIC 0 90-NONE El 99.OTHER(SPbcify): <br /> 10.RIGID PLASTIC 90.NONE 0 99-OTHER(Speciffl: 464ki. <br /> RISER SECONDARY Sq5AINMENT 1.STEEL Q 4.FIBERGLASS - SUMP <br /> AN <br /> 13".NONE <br /> 1.S]NGjl.E WALL I DOUBLE WALL 13 3.NO DISPENSERS <br /> TYPE <br /> (L MOIATM <br /> � <br /> DATE <br /> APPLICAW SIGNATURE 471 <br /> APPLICANT NAME Vint) 7�A/ <br /> ' ` -- <br /> UPCFnm-BRev.po200nm WW°=Wocs~" <br /> XVal uoz 000Z/vo/oo <br /> czo/000Oq � � <br />