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Dec 09 2009 12: 28PM STCH MRINTENFINCE 209832GO70 P. 8
<br /> UNIFIED PROGRAM CONSOLIDATED FORM ®l S ZDUNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION one form UST) t
<br /> TYPE OF ACTION (Check one item only, For an UST Dcrrllaacat closure or removel,complete only this modott and Sections 1,jr,III,N,and IX below) 430
<br /> ❑ 1,NEW PERMIT ® 3.RENEWAL PERMIT- ❑ S.CHANGE OF INFORMATION
<br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE Ej
<br /> 3,UST REMOVAL
<br /> DATE U57 PERMANENTLY CLOSED: 4302 1 DATE EXISTING UST DISCOVERED: o
<br /> I. FACILITY INF® TION
<br /> FACILITY ID#(dgcncy Use Only)
<br /> 3USIN S MS(S er FACILITY NAME or D -Dol BW1n0a A ) ,
<br /> 111
<br /> BUSINESS SIT RESS 1l03 CITY.-.•
<br /> l , tp4
<br /> �D 1 L %re"t C
<br /> If.TANK DESCRIPTIO-
<br /> TANKID# 431 TANKMANUPACTURER Or TANK CONFIGUAATION: THIS TANK is
<br /> ` 'QLI.A STAND-ALONE TANK
<br /> tA V r)m rr, C �,5 [3 2.ONE IN A COMPARTMEWITsO UNIT,
<br /> c7 {{{ Idle Oce PRO for 9911 22SMEMact In un"
<br /> DATE UST SYSTE INT LED 435 TANK CAPACITY IN GALLONS NL*M ER OF CO ARTMENTS uFNTn THE UNIT 417
<br /> 1?c�
<br /> N A
<br /> III.TANK USE AND CONTENTS
<br /> TANK USE? ❑ 10.MOTOR VEHICLE FUELING ❑ lb.MARINA PUEL[NO u lc,AVIATION FUELING
<br /> [13.CHEMICAL PRODUCT STORAGE C1 4.HAZARDOUS WASTE(mdudw Vscd ca) 3,EMBROENC'Y OENERATOR FUEL[HSC[25381.X0)]
<br /> 6.OTHER GENERATOR FUEL ❑ 93.UNKNOWN Q 99.OTHER S city): 4392
<br /> CONTENTS PETROLEUM: ❑ La.REOULAR UNLBADED ❑ Lc.MIDORADE UNLEADED ❑ Ib,PREMIUM UNLEADED 440
<br /> '3,DIESEL ❑ 3.JET FUEL ❑6.AVIATION OAS
<br /> B.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM g 440.
<br /> NON-PETROLEUM: 7.USED OIL 10,MANOL
<br /> ❑ 12.OTHER NON-PETROLEUMS cat : 440b
<br /> IV. TANK CONSTRUCTION
<br /> TYPIE OF TANK 1.SINGLE WALL Z 2.DOUBLE WALL 93.UNKNOWN 443
<br /> PRIMARY CONTAINMENT st I.STEEL 0 3.FISERGLASS 0 6,INTERNAL BLApOER
<br /> 7-STEEL+INTERNAL LINING ❑ 95,UNI(NOWN 99,OTHER S eci dd4'
<br /> SECONDARY CONTAINMit?NT 1.STEEL s,FIHEROLAy3 6.BXTERIOR MEMBRANE LINER T.IACECETED 445
<br /> 90.NONE 91,1 LNOWN 99. :OTNER S 1 "Sr
<br /> OVERFILL PREVENTION L,AUDIBLE d:VISUAL ALARMS 2,BALL FLOAT 3,FELL TUBE SHUT-OFF VALVE 4}2,
<br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION PROM OVERFILL PREVENTION EQUIPMENT
<br /> V. PRODUCT I WASTE PIPING.CONSTRUCTION
<br /> PIPING CONSTRUCTION Q I.S[NOLE-WALLED 2,DOUBLE-WALLED Q99.0THER, 460
<br /> SYSTEM TYPE El 1.PRESSURE a 2,ORAviTY 3,CONVENTIONAL SUCTIDN 4.SAFE SUCTION 3 CCR 4263 ; 08
<br /> PRIMARY CONTAINMENT L3 1.STEEL U 4,FIBERGLASS U S.FLEXIBLE 10.RIGID PLASTIC 464
<br /> 90.NONE Q 97,UNKNOWN ❑ 99,OTHER SPeci ); 11
<br /> SECONDARY CONTAINMENT 1,STEEL 4.FIBERGLASS z S,FLE 5iLE ❑ 10.RIGID PLASTIC
<br /> 90,NONE [7 93.UNKNOWN ❑ 99.OTNBR(Spx1 ): 4640
<br /> PWINO/TURBrNR CONTAINMENT SUMP TYPE L SINGLE WALL 70 2.DOUBLE.WALL 0 90,NONE 464d
<br /> VI.VENT,VAPOR RECOVERY )AND RISER I FILL PIPE PIPING CONSTRUCTION
<br /> VENT PRIMARY CONTAINMENT 40 L STEEL Ej 4,FIBERGLASS C3 10.R101D PLASTIC C1 90.NONE M 99,OTHER(Spcoily) qe
<br /> 4�41
<br /> VENT SECONDARY CONTAINMENT Lj 1.STEEL E3 4.FIBBRULASS Cl 10.RIGID PLASTIC GP 90.NONE Lj 99. -CHER(Spec*) 464E
<br /> MAA
<br /> VR PRIMARY CONTAINMENT 0 L STEEL El 4.FIBERGLASS 0 10,RIOID PLASTIC L3 90.NONE 99,OTHER(Specify) 4642
<br /> YR SECONDARY CONTAMRSENT El I.STEEL C3 A.FIBBRGI.A99 Q 10,RIGID PLASTIC 90.NONE 2641 99.OTHEA(Specify) 464h
<br /> adghl
<br /> VENT PIPING TRANSITION SUMP TYPE 0 1,SINGLE WALL El 2.DOUBLE WALL 90.NONE 4641.
<br /> RISBRPRIMaRY CONTAINMENT Lj I.STEEL U 4.FIBERGLASS L3 [0,RIGID PLASTIC W 90,NONE U 99,OTHER(Specify) 464;
<br /> 49NI
<br /> RISER SECONDARY CONTAINMENT C3 I,STEEL 13 4.FIBSROLASS 0 10,RIGID PLASTIC 0 90,NONE L3 99,OTHER(Specify) %
<br /> 46441
<br /> FILL COMPONENTS INSTALLED 1.SPILL SUCKET C3 3.STRIKER PLATEIDOTIOM PROTECTOR C1 4.C'ONTAINMIWT SUMP 451am
<br /> VIL UNDER DISPENSER CONTAROff qT(UDC)
<br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2,DOUBLE WALL3.NO DISPENSERS 90.NONE 469a
<br /> CONSTRUCTION MATERIAL 1.STEEL 4.FIBEROLASS 10,RIOID PLASTIC 99.OTHER 3 cel o
<br /> VIII. CORROSION PROTECTION
<br /> STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIALANODE(S) Q 4.IMPR139351)CURgQNT ❑ 6,ISOLATION "g,
<br /> IX. APPLICANT SIGNATURE ,,.,.
<br /> CERTIFICATIOIN: I certify Hist this UST g5tew Is compatible with the haaardeRt Mbst'aece stored ud that the In&rnuticn provided heraIR M true,accurst .
<br /> AA4 In Bill com eelee with legal ulremerts.
<br /> APPLICANT SIGNATURE DATE `)Aloe.,,
<br /> APPLICANT NAME(print)(1 _ 47t, APPLIC! E '0
<br /> }� g
<br /> .:..,
<br /> UPCF UST-B-V2 Rev.(124007) u-
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