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<br /> A PROGRAM CONSOLIDATED FO
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (o.E f=per bsT)
<br /> TYPE OF ACTION (Check one item only. Forja UST closure or rr.. 1,41,comnletr only this section and Sections 1,11,111,IV,and A1C below) 430•
<br /> ❑ I.NEW PERMITRENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION
<br /> ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL
<br /> DATE UST PERMANENTLY Ci OSED; 4306. DATE EXISTING UST DISCOVERED; 430b.
<br /> I. FACILffY RWORMATION
<br /> FACILITY ID#(Agency Use Only) _ 3
<br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3,
<br /> t N1 rvl e IZ Let- OIL -,•,
<br /> BUSINESS SiTE ADDFMS 103. CITY 104.
<br /> a VI W R A-m M!;2 LAI S-roc C-7On/ C. c7S2/9
<br /> II: TANK VE-SCRPTION:..
<br /> TANK iD# 432TANK MANUFACTURER 4t3, TANK CONFIGURATION:THIS TANK 1$ 434,
<br /> -Tiq a71=2 ' �� .��) C�'�• 1.ASTAND•ALONETANK Compteteonepngelbrcub
<br /> J '771ONE INA COMPAR'AMENTED UNIT comportment in the wit.
<br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY iN GALLONS 436. NUMBER OF COM AIL)M1rNTS iN THE UNiT 437.
<br /> o oa -2-000
<br /> III. TANK USE AND'CONTENTS,
<br /> TANK USE le.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELINGp [JIc.AVIATION FUELING 439,
<br /> 13 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAT,ARDOUS WASTE(inohede0 Used cjy ❑ 5, ;4r5XGENCY GENERATOR FUEL RISC 425261.5(c)1
<br /> _ ❑ 6,OTHER GEnRATOR FUEL _ _E395.UNKNOWNHER(Spedffy
<br /> _ ❑ 99.OT4390.
<br /> CONTENTS PETROLEUM: ❑ a,REGULAR UNLEADED 131 c.MiDGRADZ UNLEADED C] 1 b.PREMIUM UNLEADF,D 440.
<br /> L.l .DIESEL © 5.IST FURL. C36.AVIATION GAS
<br /> _m... �'❑❑❑ 1.PETROL SUM BLEND FUEL ❑ 9.OTHER PUMO :!VM(Specify): 44De.
<br /> NON-PETROLEUM; 7.USED OIL ❑ 10 IMANOL
<br /> ❑
<br /> 11.OTHER NON-PMOLEUM(SFMI : 4406.
<br /> IV.:. 'TANK CON UCTION .
<br /> TYPE OF TANK ❑ 1.SINGLE WArr, 2.DOUBLE WALL1395.UNKNOWN 443,
<br /> PRIMARY CONTAINMENT I.STEEL ❑ 3.FBERGLA$$ E36.INTERNAL 21 ADOM
<br /> ❑ 7.STEEL+TNTFRNAL LI N1N_G_ ❑ 95.UNKNOWN ❑ 99.OTHER(SpOdfy)• 4440.
<br /> SECONDARY CONTAMMENT 1.STEEL i,FIBERGLASS ❑ 6,EXTERIOR MEMBRANE LiNER 0 7.JACKET M. -�
<br /> �...,...,.._. ...145.._
<br /> ❑ 90.NONE Ur 95.UNKNOWN [399.OTHEEfy): 445x.
<br /> OVERFILL PREVt3NT TON ❑ 1.AUD113LE R VISUAL ALARMS ❑ 2,BALL FLOAT q 3,FILL TUBE SHUT-OPP VALVE 452,
<br /> 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVE L PREVENTION[ MPMENP
<br /> .w: PROI)UCt/W-ASTE'� ING.CONSTRUCTI6N.-.-
<br /> PIPING CONSTRUCTION 1.STNGLE WALL .DOUBW_WALL O 99.OTHER 460.
<br /> SYSTEM TYPE _ _ 1,(�RFSiRURE ❑ 2.GRAVITY © 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION[23 CCR 42t,31,(n�(I � 453:
<br /> PRIMARY CONTAINMENT - 1.STEEL JZ4.FMMGLASS ❑ S.F1.FXMLE ❑ 10,RIGID PLASTIC 464•
<br /> V.NON15 -p 99.UNKNOWN ❑ 99.OTHER(Softify); 464a
<br /> SECONDARY CONTAMMENT� 1.STEEL ,j 4.FIBERGLASS ! ❑ 8,FLEXIBLE ❑ 10.R1GTD PLASTIC 4646.
<br /> _ ❑ 90.NONE 95.UNKNOWN Q 99.OTHER(Speci[y): 464c
<br /> PTPING/TURBME CONTAINMENT SUMP TYPE I.SINGLE WALL DOTIBLE WALL 90,NONE -- 4646.
<br /> VI: '-EN'T;VAPOR RECOVERY(VR)AND IWER/FILL,PIPE 1'IPING"ICONSTA' p; 'ION. .
<br /> VENT PRIMARY CONTAINMENT_ I,STEEL_ 4.FIBERGLASS_- ❑ 10.RIGID PLASTIC ❑ 90,NONE_ CI 99.OTHER(Specify): 4W
<br /> VENT SECOVDARY CONTAINMENT i.STEr:L ❑4,FIBERGLASS ❑ 10.RIGiD PLASTIC jW90.NONE ❑ 99.OTHER(Specify); 464PI`
<br /> -VR PRIMARY CONTAINMENT_ !.STEEL 4.FIBERGLASS ❑ 10.RTG1D PLASTIC ❑ 90.NOW,, ❑ 99.OTHER(Specify); 464 9.
<br /> VR SECONDARY CONTAINMENT 1.STEEL fy
<br /> - ❑4,FIBERGLASS_ ❑ 10,RIGID PLASM�90.NONE 1mQ 99.OTHER(Specify); 464hi
<br /> VENT PIPiN_G TRANSITION SUMP TYPE ❑ I.SrNGLE WALL ❑ 2,DOUBLE WALL 90.NONE w 4
<br /> RISER PRIMARY CONTAINMENT 1,S'ITFL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE ❑ 99,OTHER(Speclly); _ .44664'41t
<br /> RISER SECONDARY CONTAINMENT I.STEEL a,FIRMGLASS ❑ 10.RIGiD PLASTIC ❑ 90.NONE 13 99, (Specify); 1,
<br /> FILL COMPONENTS INSTALLED 1,SPILL BUCKET 3,STRIKER PLATFA30TI'OM PROTECTOR r-1_4.CONTAiNMM SUMP 45 t
<br /> UNDER DISPENSER CIONTA;CNMENT(UDC ` .
<br /> CONSTRUCT[ON_TYPE 1,SINGLE
<br /> WALL DOUBLE WALL ❑ 3.NOD[ NONE 4G9n
<br /> � -- - 4696,
<br /> ,.CONSTRUCTION MATERIAL. f :RZEEL� 4,F1TdfRGLA33 ^1F,Q 10.RiGIDPLA-;7TC ❑ 99.OtxIER(SIxxify)
<br /> VIII. CORROSION PROTECTION
<br /> STEEL COMPONENT PROTECTION 2.SACR1FiCiAL A ❑ 4.IMPRESSED CURRENT 6.ISOLATION 443.
<br /> IX T'APPLICANSIGNATU : . . ;. .
<br /> CERTMCATTON: I certify that this UST system is compatible with the hmrdonls substance stu red an that the ieformatioe provided herele is true,
<br /> accurate and In null co Ktmce with iftal re idrements. ,
<br /> APPLICANT SIGNATURE
<br /> DATE11 470,
<br /> APPLICANT NAME(prim) r S� /t 471. APPLICANT TITLP 472.
<br /> UPCF UST-B Rev.(I212007)-112
<br /> www.eeidoCanrg
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