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+ r <br /> UNIFIED PkIbGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK " <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION ono lbem Pa UST) <br /> TYPE OF ACTION (Chock ono item Only. For an UST pelmaaent closure Or removal,mWids 0*this taction and Saatiou 1,II,III,IV,and IX below) <br /> 490 yj <br /> 3.RENEWAL PERMITS.CHANGE OF TNFORMATTON <br /> ❑ T.NEW PERMIel <br /> [] 6.TEMPORARY VST CLOSURE D 7.UST PERMANENT CLOSURE ON SITE R.S.8UST REMOVAL u <br /> DATE UST FMOLkNENTLY CLOSED: _ <br /> .NY <br /> FACILITY 15#(Agency Use On{y) <br /> BUSINESS N (sse as FACILITY NAME or DSA- in$ra H <br /> 04 <br /> BUSINEss SITE ADDRESS S03 CITY 1 <br /> 431 TANK MANUFACNRER 03 <br /> TANK CONFIGURATION:TM TANKS �j � `� 434 <br /> TANK ID# �/,©� ��`� �yAo/1 f�,�/� ❑1.A STAND-ALONE TANK v <br /> 0 2.ONE IN A COMPARTMENTS UNrr.. �! <br /> ex Israel t3aun�ms 437 <br /> DATE��UCC3T445 -STEM 'C TANK C C G NS 43/6y N(WR'OF COMPARTMEI3T S IN�UNIT <br /> TANK US8 a bIOZOR VEHICLE FURLING ❑ Ib.MARINA FUR1dNG ❑ Ia AVIATION Y GENNG <br /> 439 <br /> 'j7 ❑ 3.CHmcAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Qeobdm Usvd 030 (35.�i8r1C7f G>�IBRATOR PC1EI.1tt8C 4asat l.5(e11 439a <br /> t1 ❑ 6.OTRER GENERATOR FUEL ❑ 9S,UNKNOWN O 99.OTHER(S9eoify: 0 <br /> CONTENDS pBTROLMAL. [3Ia.REGULAR UNLEADED [31o.)=GRADE UNLL1%DED C3'tb,PRffiAUM UNLEADED <br /> P•3.DHD81. ❑ s.in FUEL ❑ 6.AVIATION GAS 4404 <br /> 12 L PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM ( c' <br /> PETROLEUM:0 7.USED OIL 0 10.ETHANOL 440b <br /> 11.OTIM NON-PSCROLEUM. <br /> I.SINGLE WALL 2 WALL 95.UNRNDWN 443 <br /> TYPE P TANK 444 <br /> PRIMARY CONTAINMENT .STEEL E3 3.PMERGLASS ❑ 6•I1V'IEWAL BLADDER 444a <br /> 137.&Tm+1N11EtNAL LINING D 9S.UNKNOWN ❑ 99.OTBER S 44s <br /> SECONDARY CONTAINMENT W.STEEL Li 3.FIBERGLASS (] 6.E7CrE WR MEMBRANE L1NBR <br /> 90,NONE ❑ 95.UNMWN ❑99.OTBERis 4sa. <br /> OVERFILL PREVENTION 1.AUDIBIAVISUAL ALARMS L BALL AT 3,FAL TURS SHUT-OFF VALVE <br /> 4.TAMC MEETS CIlRBIv18NT8 FOR VUMWMN FROM OVERFILY.PjEvIWnDN EQUIP3�NT <br /> 450,.: '. ,:. .'., .`; 1. ...I.'�:.: +T.�r :.., •_.•W.......,.. yrr4 ..-:. <br /> FngNG CONSTRUCTION 1,SDIGL&wAuED UBLE-WALLED .' 99.0'HER 45SYSTEM TYPE p ❑ 2.GRAVITY 3.CONvENnONAL SUCTION 134.SAFE SUCTION[23 CCR;a W&X3) <br /> 464 <br /> PRIMARY CONTAR&G3NP 1.STEEL 4.FIBERGLASS 8.Fi>OLII3LE 13 10,RIGID PLASTIC 464a <br /> 9o,NONE ❑ 93.UNKNOWN ❑ 99. 1: <br /> SECONDARY CONTADDdENT 1.STEEL PBIE[tGLASS B P! 7.R i0.RIGID ELASTIC <br /> 13 90.NONE ❑ 9S.UNKNOWN ❑ M.OTHER ifi'}: <br /> PIPING/II1RW NE CONTAINMENT SUMP TYPE ❑ I..SINGLE WALL WALL_ �-01 <br /> FIBERGLASS 1 .RIGID PLASTIC ,.• 90. 99. {$ 64cl <br /> VENT P Y CO46412 <br /> NTAI 1.Slt;SL a64e, <br /> FIDEROLASS 1p RIG1D PLASTI 90.NONE 99.01it10t(SpeeitY) "Or <br /> VENT SECOND Y CONTAINMENT 1. 4sati <br /> VR Y CONTAINMENf 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE K OTHER,(Specify) i <br /> VR SECONDARY CONTAIfAMPNr L3 1.STEEL CM.4 FIDEROLASS 10.Rim Punic 90,NONE M 99.OTH8R(specify) 46' <br /> 4661 <br /> VENT PLPING ON SUMP TYPE 1.SINGLE WALL DOUBLE WALL 40.NONE 464 <br /> RISER PRIMARY CONTAINMENT 1.STEEi. •FIBERGLASS 10,RIGID PLASTIC 90.NONE 99.OTHER{S�a4 AM <br /> - <br /> 0 <br /> RISER NDARY CONTAD MBNT 1.STEEL i�6RCiLASS 10.RIGID PLASTIC 90.NONE 99.'0 OTHER(SpeasiY) 4601 <br /> Init PLA &WTIOM COMPONENTS L6ISPALI.BD 1,SPILL.BUCKET 3.riltKBR R A <br /> CONSTRUCTSON TYPE 1 BII�IGLB WALL DOUIU WALL U:3.NO DISP>:�S 90.NONE <br /> CONSTRt7CTIONMATERIAL 1.8786E ,s'..t. 4t" 77777 <br /> r - <br /> FIBERGLAS <br /> STEgL <br /> COMPONENT PROTOCTION p 2.6ACRIFW AL ANOAE(S) 0CURRENT 'E3 6.ISanimAi <br /> C6RTIFICA ONS I oft"tut a"UST systwn is compatible With the hourdoax nbstsaee tiered 984 that the infornutioa provided hgreila!s g eeearit% <br /> sad in fall ce ee e1e <br /> APPI.ICANTSIGNATURB DATE <br /> d" a73. APPLICANTTITLE <br /> APPLICANT NAME • <br /> n. <br /> Ems` <br /> Iter.(la/Z0971 <br /> UPCF UST.B-1l2 <br /> Wd Z0:9L 60OZ L 2nV 0L6L99V60Z:Xe3 10d 30 NVA <br />