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WIMFID PROGRAM CONSOLIDATED Fp
<br /> UNDERGROUND STORAGE TANK ��
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One rbrM per T)
<br /> PE OF ACTION (Check one item only. For a ST closure or removal,complete only this section and Sections I,1I,I/l,IV,and 1,Y below) 430.
<br /> ❑ 1.NEW PERMIT 3o RENEWAL PERMIT ❑ 5,CHANGE OF INFORMATION
<br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8,UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 4300. DATE EXISTING UST DISCOVERED; 430b.
<br /> L 'FACII,M INFORMATION
<br /> FACILITY ID 0(Agency Use Only) 1;
<br /> BUSINESS NAME(Satre as Facility Nome or DBA-Dobig Business.ss a,
<br /> Mt,=Y2- c a � � L��
<br /> BUSINESS SITE ADDRESS 103. CITY 104.
<br /> 330 • W.
<br /> HP
<br /> m a2 l.rV S o dC70�
<br /> II.. TANK DESCRIPTYUN .
<br /> TANK ID# 432- TANK MANUFACTURER 433, TANK CONFIGURATION;THIS TANK IS 47
<br /> f, ( -` E3 L A STANNALONE TANK Complete(me ppge for owh
<br /> GC J �-L 2.ONE IN A COMPARTMSNCED UN(� eompnKmeni in Me unit
<br /> DATE UST SYS1 P,NI INSTALLED 439• TANK CAPA TY IN GALLONS 6• NUMBER OF COMPARTMENTS IN THE UNIT 437.
<br /> O Q o 2--
<br /> III. TANK USE;t1 AND CONTENTS
<br /> TANK,USE Is.MOTOR vieHiC-6 FUELING ❑ Ib.MARINA,FUELING ❑ 1 e.AVIATION FUELING 439•
<br /> Ct 3.CHEMICAL PRODUCT STORAGE ❑ 4.RA7�ARDOUS WASTE(incktdea Used Oil) ❑ 5,WERGENCY GENERATOR FUEL(ASC§2=1,501
<br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN __ LiER 99.OTH (S�eci� 439a
<br /> CONTENTS PETROLEUM: C3iA,REGULAR UNLEAi)F,0 �"~ Ic.MID(iRADFUNLE_ ADED 1b.PREI4IICTMT]NI.F.AbF,D 440.
<br /> ❑ 3.DIESEL [15.JET FUFT, 'C) 6.AVIATION GA$
<br /> ❑ 9,P13'CROLEUM BLEND R iL ❑ 9,OTHER PETROt,RW(Specify): 440x.
<br /> NON-PETROLF,LW.❑ 7,USED OIL ff 10.ETTTANOL
<br /> ❑ 1 I.OTHER NON-FUMOLEUM 440b.
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OF TANK I.SINGLE wALt .DOUBLE WAL, _❑ 95.UNKNOWN 443.
<br /> PRIMARY CONTAINMENT 1.STEEL Cf 3.FIBERGLASS ❑ 6,INTERNAL BLADVER 444.
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER(ASFoclfy): 444x,
<br /> SECONDARY CONTAINMENT T,STEEL FIBERGLASS E36,EXTERIORMEMBRAMUNER [37.JACKETED _..__.._44S'..
<br /> ❑ 90,NONE 5,UNKNOWN ❑49,OTTIER(Sp-qty): 445n.
<br /> OVERFILL PREVENTION Q t,AUU113LE&VISUAL ALARM$ ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE °S2
<br /> 13 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERML PREVENTION 9QUTPWNT
<br /> V. PRODUCT/WASTE PIPING CONSTRUCTION':.:
<br /> PIPING CONSTRUCTION !p_1,SINGLE WALL _DOUBLE WALL ❑ 99 OTt!MR
<br /> SYSTEM TYPE PRESSURE ❑ 2.GRAVITY_ ❑_3 CONVENTIONAL SUCTION ,(]4.SAFE SUCTION 123 CCR�+6(�1• 456,
<br /> PRIMARY CONTAINMENT 1,STEEL 4,FIBERGLASS ❑ 8,FLEXIBLE ❑ I0.RIGID PLARTtC 464,
<br /> _ ❑ 90,NONE 9$,UNKNOWN_ ❑ 99,OM2M(S-if 464x,
<br /> SECONDARY CONTAINMEN STEEL FIBERGLAIM C33.PLEX1BLfi ❑ 10.Rldn)PLASTIC --- 464b.
<br /> ❑ 90.NONE 0795,UNKNOWN 99.OTHER(ST*dfy); 4640,
<br /> PIPING/TURBINE CONTAINMENT SUMP TYPE J9 1.STNGLE WALL 2,DOUBLE WALL ❑ 90.NONE 464x•
<br /> VX:'VENT;VAPOR RECOVE Y(VR)A ''R.1"M /k'I -L PII'E PIPING`CONSTT"tUCTION
<br /> VENT PRIMARY CONTAINMENT it I.STEEL 4.TINERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.07TTER(Specify): 4096
<br /> VENT SECONDARY CONTAINMENT- 1.STEM ❑4.FMER016ASS ❑ 10.RIGID P.T,ASTIC 90.NON13 0 99.OTHER(Rpeuify); 464nf
<br /> VR PRIMARY CONTAINMENT - I.STSEL 4.FTBER)LASS�❑ 10.RIGID PLASTIC ❑ 90.NONFE3 99,OTHER(Specify);
<br /> VR SECONDARY CONTAINMENT I.SM ML ❑ 4.FIBERGLASS❑ 10.RIGID PT,ASTICV90.NONFs ❑ 99,OTT MR(Specify); 46 hf'�,.......,.,,..�.�._--__..�,,,,
<br /> VENT PIPING TRANSITION SUMP TYPE E3132,D 1,SINGLE WALL DOUBLE WALL, 90.NONE 464.
<br /> -E _�_.._.,. O � __�........_....
<br /> RISER PRIMARY CONTAINMENT 11 STEEL ❑4,F113ERGLASS ❑ 10.RIGIDPLASTTC ❑ 90.NONE ❑ 99.OTFIER(Spwify); R
<br /> RISER SECONDARY CONTAINMENT 1,STEEL JW4,P113ERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Speclfy); 464
<br /> 464k1
<br /> FILL MPONENTS INSTALLED 1.;SPILL BUCKET a 3.STRIKER PLATFIBgrTom PROTECTOR 4,CONTAINMENT SUMP 451n.c.
<br /> UNDER DISPkNSER 'C) ,
<br /> CONSTRUCRON TYPE 1.�SINGLE WALL
<br /> __,4_2.DOUBLE WALL 0 3.NO ATSPENSERS T(] 90,NONE _ 469.L
<br /> CONSTRUCTION MATERIAL 1,STEM 4,_>:IBERGLASS ❑ 10.RIGID PLASTIC
<br /> ❑ 99.07 FIER(Specify) 4690,
<br /> VIIh CORROSION PRO'T'ECTION
<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRTFICIAL ANOb S ❑ 4,IMPRESSED CURRENT 6,ISOLATION u18•
<br /> IX. APPLICANT SIGNATURE
<br /> CERTIFICATION: I certify that this UST system is compatible with the haurdous substance stored and that the information provid hereiif Is true,
<br /> accurst 2Tkd in fall c0m0UAWeqdth legal reavirements.
<br /> APPLICANT SIGNATURE DATE 470.
<br /> t-.
<br /> APPLICANT NAME(print) T ' 471, APPLICANT TITLE _ "` 471
<br /> UPCF UST-8 Rev.(1212007).V2 \ www unidoce.org 7
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