|
JUL-1-2008 07:59A FROM: .' TO:4683433 1�1 '
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION -TANK INFORMATION (One farm per UST)
<br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,11,111,IV,and IX below) 430
<br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT t[ 5.CHANGE OF INFORMA-1.10N
<br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7,UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 430a. DATE EXISTING UST DISCOVERED: 430b
<br /> Y� FACILITY INFORMATION
<br /> _I
<br /> FACILITY ID N(Agency Use Only)
<br /> BUSINESS NAME(Same as FacilityName or DBA-Doing Business As) 3
<br /> C1 -loCS`r-C.'_AO 1--oo's
<br /> BUSINESS SITE ADDRESS 103 CITY 104
<br /> e l -L)0/0'& S1 • OCr c�
<br /> II. TANK DESCRIPTION
<br /> TANK IDN 412 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434
<br /> QwenS Corr,t0-N101) 05I.ASTAND-ALONE TANK Complete one Paso lot each
<br /> ❑ 2.ONE IN A COMPARTMENTED UNIT companmem in the unit
<br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENT'S IN THE UNIT 437
<br /> Q
<br /> CIT. TANTS USE ANI)CONTENTS
<br /> TANK USE 1a,MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ le.AVIATION FUELING 439
<br /> ❑ 3,CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDUUS WASTE(Includes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)]
<br /> _0._6.OTHER GENERATOR FULL _._....__.. .._._.©...95__UNKNOWN _ _._...._..,.,._ _:...»._ 0_99.t7fHER(Speafy)„ 4308 a
<br /> CONTENTS PETROLEUM: la:REGULAR UNLEADED Q Ic,MIDGRADE UNLEADED ❑ [b.PREMIUM UNLEADED
<br /> J] A40
<br /> 1 3.DIESEL ❑ S.JET FUEL ❑ &AVIATION GAS
<br /> ❑ 8.PETROLEUMBLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a
<br /> NON-PETROLEUM:❑ 7.'USED OIL_. :...,_..._. ....,._...._�©-IO�ETHANOL ._..__
<br /> © II.OTHERNON-PETROLEUM S ecif : 440b
<br /> IV. TANK CONSTRUCTION
<br /> 'TYPE OF TANK ❑ I:SINGLE WALL A2.DOUBLE WALL ❑ 95.UNKNOWN 443,
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL3.FIBERGLASS ❑ 6.INTERNAL BLADDER
<br /> ❑ 7.STEEL+rNTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(S,pecify)� 444a
<br /> _......._...___.__._.........__._.._._... ....,,_.__.._..,_...___...._..,. . ......_._..-.._._...___...._..__�.._,_...__._..__.___.........__.w..._._.._._._.
<br /> SECONDARY CONTAMMENT ❑ 1.STEELS.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99,OTHER(Specify)' 445a.
<br /> OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452
<br /> © 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br /> V. PRODUCT/WASTE PIPING CONSTRUCTION
<br /> PIPING CONSTRUCTION ❑ I,S[NGLE WALL 2.DOUBLE WALL ❑ 99.OTHER _ __
<br /> _
<br /> x60
<br /> .. .__..._..._.,......_.._..,..._....._._.._,,.._. ...458._
<br /> SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3,CONVENTIONAL SUCTION ❑ 4,SAFE SUCTION(23 c(i §2636(x)(3}]
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL jX4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464
<br /> ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify: 464x.
<br /> ___..__.___._._.....,_._.._,.___....__._.___._,..._...__.,._.. ___._____ ._ ._ .ec_t..
<br /> SECONDARY CONTAINMENT ❑ I.STEEL4,FIBERGLASS ❑ S.FLEXIBLE ❑ 10,RIGID PLASTIC 464b
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SQecify , 464c
<br /> PIPiNG/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d
<br /> VI: VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION
<br /> c.
<br /> VENT PRIMARY CONTAINMENT [31.STEEL 0 4.FIBERGLASS C310.RIGID PLASTIC [390,NONE [199.OTHER(Specify): 46ae
<br /> VENT SECONDARY CONTAINMENT ❑ r.STEEL 0_4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464fl
<br /> VR.PRIMARY CONTAINMENT _ ❑ 1.STEEL_❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46a 1.
<br /> �VR SECONDARY CONTAINMENT ❑ L STEEL of 4.FIBERGLASS }❑ 10.RIGID PLASTIC ❑~90.NONE ❑ 99,OTHER(Specify): 4601,
<br /> VENT PIPMG TRANSITION SUMA TYPE ❑ L SINGLE WALL f9 2.DOUBLE WALL ❑ 90.NONE
<br /> RISER PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS [3 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify): 464x1
<br /> RISER SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OT1iER(Specify}: 464k1.
<br /> FILL COMPONC-N'IS INSTALLF_D M I.SPILL BUCKET ❑ 3.STRIKER PLATE/130-170M PROTECTOR ❑ 4-CONTAINMENT SUMP 451x-c.
<br /> V:iI, UNDER DISPENSER CONTAINMENT (CJDC)
<br /> CONS'T'RUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS [:190.NONE 4694.
<br /> CONS RUCTION MATERIAL
<br /> .STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC [399.OTHER(Specify) 4091)
<br /> VIZI CORROSION PROTECTION:
<br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4,IMPRESSED CURRENT a 6.ISOLATION 448
<br /> IX,: APPLICANT SIGNATURE
<br /> CERTIFICATION: I certify that this UST system Is compatible with the hazardous substance stored and that the information provided herein is true,
<br /> accurate,and in full compliance wit legal requirements.
<br /> APPLICANT SIGNATURE , DATE 6/ /a, 09 470
<br /> APPLICANT NAME(print) 1CU�J': m• L-tC12 471 APPLICANT TITLE v' �t rCS 3 412
<br /> UPCF UST-B Rev.(12/2007)-1/2 wwwainidoes.org
<br />
|