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04/18+//22013 11:47 2093344684 #5032 P.007 /020
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<br /> UNIIFrYED1 PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INIFORMATION lone form perUST) {�
<br /> TYPE OF ACTION (Check one item ply, For an UST permaoeat unsure or removal,compcv only this seom and=act=
<br /> I,it,t!!,Iv,aad I3{below)
<br /> ❑ i,NEW PMWT ® 3,RENEWAL PEP Uff 1715,CHANGE OF INFORMATION
<br /> ❑ 6.TEWORAR'Y UST CLOSURE 7.UST PERMANW CLOSURE ON SITE tj S.UST REMOVAL
<br /> DATE USF PERMANENTLY CLOSED: °J°` DATE EXLRTING UST DISCOVERED:
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<br /> BUSINESS NAME(&uV as FACILITY NAME,'or DBA-Dobw,13u5iam5 As) 3
<br /> 11191OX 00 tr+T
<br /> }I+IE$S S!T$AI)1?RES 103 Cly Jr loa
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<br /> TAMC ID# f 432 TANK MANUFACTURUR TANK CONFIGURATIUN:THIS TANK 19 434
<br /> D h rE 1.AC'aMPA R
<br /> NI).AN
<br /> 2.014E IN A
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<br /> DATE UST SYSTEINSTALLED 435 TANK CAT/4� Oil i+t5 � NUMl31.R OF Ci�lft
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<br /> TANK USE 1s MOTOR VEHICLE PUE1 iNG ❑ 1b MARQIA FUELING
<br /> ❑'to AVIATION FUEa.ING.UEL 439
<br /> 439
<br /> 3 GHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(mchdCs Uma W ❑ 5r EMERGENCY GENERATOR FUEL MC t]sstsl.3(e>2
<br /> ❑6.aTHt3t CaENERgTOiE FUEL ❑95,lJNKNOWN ❑99.OTHER(Specifyk 43%
<br /> CONTENTS PETROL)yUUM �-la REGULAR UNLE4DED ❑ 1c t�CdLADE UNLEADED Q lb,PREMRJM UNLEADED 440
<br /> © 3.DIESEL Q S.IETFUfiL ❑
<br /> 6.AVIATION CA$
<br /> ❑ $.PEIROLIIIAQ g!ENI)FUEL Q 9,OTt1ER PETROI ELJM 440a
<br /> NON-PETROLEUM:❑ 7.USE17 IL ❑ l0.ETHANOL
<br /> ❑ I I.OTHER NO
<br /> 4444
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<br /> TYPEOF TAMC 1.364Cd.E WALL MKZ DOrmt>^WALL 95,Ut+lKATOwN 443
<br /> PRIMARY CONTAilRMENT 1.STEEL ❑ 3.FmERO Ass ❑6.II41IERNAL VLADDER 444
<br /> ❑7.STEEL+INTERNAL LIKING ❑W.UNKNOWN © 99.OIHER ( 444a
<br /> SECONDARY CaN7AiNA4ENT 1.STE6t FIBERGLASS ❑6_EXTf?MIM M&ABRANE LINER 4 7.JAMSITED 445
<br /> 8.
<br /> 9or NONE ❑95.UNKNOWN 99_0r1m ). 445,
<br /> OVPRFILL PRIzVhMION 1_AI1DtBLE&VISUAL ALARMS 2.6AI,1,FLOAT FILL SHUT-OFF VALVE 452
<br /> Q 4,TANK MEM REQUIRE[r11'M FOREMMpTION FROM PERF EQYWME4�� Y T
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<br /> p9P114GGONSTRUCITON I SlI4GL&WALLED DOUeLBWALLED .OTHER 460
<br /> SYSTEM TYPE !.PRESSURE ❑Z,GRAVITY [13.CONVENnONALr SUCTION ❑4.SAFE SUCTION M CeR¢1636t 458
<br /> PRIMARY CONTAINIvniNC 1.STEEL M4.FIBERGLASS 13 &FLEXIBLE ❑ 10.Mom PLASTIC 460
<br /> ❑90,NONE ❑95,UNKNOWN [3 OTHlrR(S 464a
<br /> SECONDARY CONTAINMENT ❑ 1.STEM. IQ4.FrOERGL.ASS (] $.FLEXIBLE 10,RIGID PLASnC 4646
<br /> ❑90.NONE `0 95.UNKNOWN ❑99.olum(Specify). 4W
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<br /> VFtdT PRIMARY AINMENT I.$T EEL 4.FIBERGLASS 10 PLASTIG 90_NONE 99.OTI nsR(SpcetBj) 460E
<br /> 4640
<br /> VENT SECGDIDARY CONTAII ilv1ENT 1.3TFE[ ❑ 10.RIGID PLA57TC 9Q NONE ❑99.OTHER(Specafy) 4G4f
<br /> 464fl
<br /> VR PRIMARY GONTAIId{dEN7' 4.F}l31JtGLASS 10.RIGtiP ELASTIC 90,NONE 99.OTHER(Spn�y) 464g
<br /> SECONDARY CONTAINt4lfiRTt ❑ I.5TEE1 ❑4. LASS !0.R1G[p PLASTIC 90.NONE 99r OTHER ) 4641,
<br /> V�Tf G TRANSrn0N$UMP TYPE ❑ 1.S E W i1
<br /> ,1)CILBLE W AT-1- 94.NONE 464;.
<br /> RISER PRIMARY CONTA04 AWT JW,1,STEEL 4,F $ ❑ 10.RIGID PLASTIC 9Q NONE ❑99,OTHER ) 461
<br /> RISER SECO ARY CONCAM&W 1.STEE7 4.FIBER 10,RIGID PLAS91C ❑90.NOM El 99.OTHEIt( y) 4641
<br /> FILL C NEM$it45F 46411
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<br /> SSYEUCrIGNMA=AL 1.STEEL ❑4.F18
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<br /> CERTstWW and that rthe
<br /> 1T?ICATtt)N:ICertify , this sm is tahle with i�rdpls snbstauCr t ao ' e provided herein is
<br /> and in fall sq
<br /> APPLICANT SIt3MTU
<br /> j' DATE
<br /> APPLICANT NAME(print) �i K--/! � APPLICANT n17LE r
<br /> U16CF'UST I3-I/2 Re+;
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