|
11I'0��4}/•16/2013 11:48 2093344684 #5032 P.008 /020
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK t
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per US 17
<br /> FTY�PEOFACIIOIN (Check one item only. Fqr UST pmnawt close m ex removal,compkbc only this - and Sextions 1,11.111,TV,and IX bel(rw) 430
<br /> ❑ 1.NEW PERMIT W 3.RENEWAL PwwT 5.CHANGE OF INI:ORMATION
<br /> © 6.TEMPORARY UST CLOSURE7.UST PERMANENT'CLOSURE ON SITE 0 S.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED_ DATE EXISTBMG UST DISCOVERED: g3ab
<br /> ..:p«;,;%{.0%S.:^kir,.:a':--•:=�_..,...Frrnn«Jr�ir.c:.-.:::•.r..::..;_.•.-•,.,.x •ar"--.,.-,,.,....�..%....., -- _
<br /> FACR TY ID¥(Agency Use 0*)
<br /> 13 SINESS N (Ssmc as FACUATY NAME ol DBA-Doing Busies As) s
<br /> Gt/Z Gam`
<br /> 13 S SITEADD S 143-71 �y/ ,,o 10Q
<br /> .. ........
<br /> nt:r.a,'.m: r ,a•,_a:i:.;,. .� n'r.'.,...,.x=rns,^rc-;.:..,rm[.-::::_:::,it;�:.,::-:-::.`- ......- .�ac-��x'��:M:•,::�'r.'::G'r' ,nsnry...,.,_.�.,__•FM1•,.
<br /> wxr.-.n•"..rrr.::--�i��': ,'Lre��, d .._.r,��x^e::.,-.;,;:
<br /> V"Y •E ...-»._.» .,:.,..�C'r=.
<br /> TAMC ID# 4n TANK MANUFACTURER 43s TANK CONFRKMATIM:TM TANK U Ota
<br /> CI A STAND-ALAN6 TANK
<br /> ✓ 42iw ��//�"f .OIC lAl A COMPARTMIROSD UNIT.
<br /> DATE UST INTANK CAPAC IN LON3 ° ' NUMBER pF Cf,��iPA 14TS IN THE UNIT 437
<br /> �J "(
<br /> _.'___"_.__»__iv:-:.._swa . .•:..F.-=,°'_:i�G na:..r^•1..::.._»J,;'u::;,�rs�„�:f'�}.f��r. r" -_ _ -:xriE•im:x,e ..._ -
<br /> ,....t...................... _._...__ pAtru,u.-t._, )"�ywx.�.,.-._r,.. Pi. rni .• : .. - - ...{ v
<br /> M,x._..«.UIRnh:aT.L..... rwn,ra_rx.,_...�JF.'��^.Y.:y. Y::':w: ..:.x,a..�.,.',_•Li1rJ:':: tI.N:r . .. _ -M•iiY:'l�,""'�-- ,4f'^:.1, _ �NC•
<br /> i�'xnvrtlti.i�� -.
<br /> TANKUSE AJ&MOTOR VEHICLE FLEW NG �YLL
<br /> ❑ 16.MARINA FUELING ❑ la AVIATION FUELING - , _.--4"i
<br /> ❑ 3.(`rrDALCALPROIWt'TMRAGE ❑4-IIA,ZARDOU9WAST8(mctadc*wwM ❑ 3_ GiNI'YCl£NF�EtATOR117$I IBSC Szse•s(eN
<br /> 6.OTHER GENERATOR FUEL ❑95,UNKNOWN ❑99,On-M(Spooi&t 439A
<br /> CONTENTS PETROLEUM ❑ ,a REGULAR UNLEADED ❑ is MI DGRADE VNLEADED
<br /> ❑ III.PREMIUM I1NI 1CAni±n 440
<br /> DIESEL ❑5,JET FUEL, ❑ 6,AVIATION GAS
<br /> &FEfROLIIUMBLENDFUEL ❑9.OTHERPETROLb•UM 44011
<br /> NON-PETROLEUM:0 7.USED OIL D 10,ETHANOL
<br /> ❑ I1.0=NON-PE71'tOLEUM 4406
<br /> .._.._.._-_' --...ifNN�:k!:::-':_:'-p ......_...,•, Wti-.._-._. '4n,.':. ......._.,,.,_, ._...• '_ _ _ ww,rz.�_,�..p.;�F�..p. l�A^ti i,Vl-'hw:- iSi y«.:T�..
<br /> TYPEOFTANIC - -._.....__. ...._,_...._.-., ::.,,,.�._:._.__._.. .;.::•=:::!•�-�^-�r.�r'<:::�s,-_;• --
<br /> ❑ 1.SENiGIE WALL
<br /> 1�� DOUBLE WALL ❑95,UNKATOIVN
<br /> 443
<br /> PRIMARY CONTAQll�NT J"".STEEL n 3.FIBERGLASS ❑6_INTERNAL BLAMER 444
<br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95,uN KW)WN ❑99,OTHER ); 4440
<br /> SECONDARY CONTAINMENT ❑ l_STEEL FIBERGLASS Q 6_EXTERIOR MEMBRANE LINER 7,JACKITIFD 445
<br /> ❑9o.NQNF ❑45.UNKNOWN ❑ P.OTHER ): 445A
<br /> PRavEN170N U I_AUDIBLE&VISUAL ALARMS ❑2.FALL FLOAT ❑ 3.FILL TUBE SITYTT-(FF VAL 45Z
<br /> ❑4_TANK MEETS REQUIREMENTS FOR EXEMtnT N
<br /> O FROM OVERFILL PREV N
<br /> EQUIPMENT
<br /> UiPMENT
<br /> ,;yr}= --=''-=max ..•r: x....r^ `.i. siap�'i
<br /> 1'Sn..-wY !�.!!4.".!H.. -..•iii•��:1 ..
<br /> P1P1t3GCOdJS7RIJCI'ldr4 1I.
<br /> 2.DOUFL[«wAtLEU ❑99,01TiER ,:.��-��-� -. --!= �,
<br /> sYSTIBMTYP) .PRts55URE 2 tiRAvfIY 3.(`QNVEN7gONAI SuCnON ❑4.sAFE5UC1TON112gOM )1
<br /> PRIIMARY CONTAINMENT El L STEEL ❑4,FIBERGr nce $_FI E7QBI$ 10,RIGID I1 ASIIC qua
<br /> ❑90.NONE ❑ 95,UNKNOWN 99,OTHEIt($pedb k 4640
<br /> SECONVARY CONTAENMENT r3 1_STEEL A r yq„a$ 0 g}Z g ❑ L0,RIGtb PLASTLC 46Rs
<br /> ❑90-NONE ❑95.11NKNOWN Q 99.OT1E8R 464e
<br /> F1101011iMME CONTAIIQMENI•SUMP TYPE 1,SINGLE DOLIBL E WALL NOW 4w
<br /> ,..,_�....nar_:........... ........ ,__._:._ r......,.. ......,......,.,... .,...�..._ _' __.- ...._ .... ...e:.» .... ... . ...'t�'• ••.' Cru'r�iLt�•,:,,�x
<br /> om
<br /> VNfFi&DNY CONTAnQ4ENT ,MUM ❑4.FIBERGLASS U 10.RIGID PLASTIC U 90-NONE Ll 99.OyHER(Specify) -- 4640
<br /> VlsT1TSBCONbARYlJONT 4,FIB 10 RIGID MASTIC 5QFNONE ❑99.OTFli (Spoeit3) 46401464E
<br /> 460
<br /> VR M51AXY CONTAINMENT sisal. o 4,FIBERGLASS ❑ 10.RIGIDPLASTIC ❑90.NONE 99,OTHER(Sp eafy) 464g
<br /> VR SECONDARY CONTniNMENTT 0 t.STEEL 4.FSBt RGLASS D 10.RIGID PI.Ab'F1C NONE ❑994"9t,OTHER(SPW*) a64>r
<br /> PIPING TdANSTT[ON SUMP TYPE 1.SINGLE W 2.DOUBLE WALL NX NF, 46&
<br /> RISER PRIMARY00N L STEEL U a.FIBERGLASS E3 10.RIGID M AST IC ❑ 90,NONE 44,OTHER(Specify) 46dj
<br /> 1
<br /> R1SAt SECONDARY CONTAINMENT ❑ I•STEE4 10.RIGID PLASTIC Ll 90,NONE ❑99.OTHER(Spw*) 464k
<br /> 464kt
<br /> FILL COWONENTS INSTALLED 1,SPIL pgp�Og
<br /> BUCKET
<br /> 3. P1.A
<br /> TTOAf 4.
<br /> .,:._..�.,;-'___.., _ _ - __ _ SUMP 451a�c
<br /> '«r".:-' Ja'•.Ina..:.....-, «},lr:..:.-...,..,.. .. .. :,..._-:..
<br /> \. x..-....-.._........... - - -_
<br /> CON8TRUCTIONTYP£ ,SINGLEW "'�••'• :.rrx�,;,,:,,,,.,...nM., ..-;.,,__
<br /> ❑2x DOUBLE WALL ❑S.NO DtSFENStR.S ❑90.NONE 40%
<br /> CONSTRUCTION LAATMAL Exi.STEEL1 MASTIC.RIGit3 99.
<br /> ,.._._•,t.xri�;. ,-: t,,.�'r..-.::-<.. :z-;;-.suer-':a•,:<.xW« ,.. .. ....
<br /> .: ..,._•_____...�. xL««l'Ik._..,�...... ._.. .,,.,_.x�. ,,•:.. �%, di'i�::r':::.^1n r:Ytt•"'.�-_•. Crt.Fw.�r�:is�.,:,y.::'�1:�:,:Mq�,i,c:-:
<br /> ..:•tx..J.............. ......,_.. _-...____._,wrr_.s,_a,,,w..f,.,..kibl ..... .......... ,� . , - _
<br /> STEEL CDMPUNBN't ❑ 2 SACRWICUL - a; w.;,,•:.:a. ..r; r i s:(;a:.?:,::44L
<br /> s «x:. _�.. r. ._:�,..x,d}}�,...gr.+�:,.h:^,.•. ..,__ :_.:. '. _-.�'' ISOi�A,J.•Y:,_:•_.rL: _:.c• «•gig;::
<br /> np*;x:,.,�'-----,r kar«wm,..., r.Y•,-,,. _-. .,r...........,,,w -'Fi;.._ .:._. - - ::iwi?'
<br /> i6-
<br /> ' yn•.:.:::r:..J.t......"..'fi^;•':'^zh=s,;�...,,...,,:�N.���V'L�:NVA•:^:':::�. ,,, ! jy
<br /> CERTNICATION,I thaa;�,h::-�L?�
<br /> t system is compstibie the bs�rdoas sRbeltanlx stored rmd that tl3e informs provldgl ty
<br /> and hi fan 4o
<br /> APPLICANT SiCNA DATE i�� / ;, 4
<br /> APPLICANT NAME(pr*A)p j //�S/ �{'j/ .st4B APPLICANT TTI7.E
<br /> (MCP UST-B-D7 `'
<br />
|