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07/10/2009 10:34 2098585OGG �!)TWO GUYS FOOD PAGE 07108
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<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PEST APPLICATION--TANK INFORMATION (Onc t�tm Dor US7)
<br /> TYPE OF ACTION (Check one item arty. For a UV doxwe or removal.complete:only this saetiorr and Sections 411,111,fY,ami I.tCbelmv) 430.
<br /> © 1.NEW PERM)T Q 3.RENEWAL PERMIT' ®® 5.CHANGE OF INFORMATION
<br /> 6,TEMPORARY UST CLOStJRE p 7.UST PERMANENT CLOSURE ON SITE © S.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: aa0a DATE EXISTING UST DISCOVERED: 431R�
<br /> ., 77 .... .L..;�AGILI'I`X.INFORNxATIOrT..,
<br /> FACILITY ID#(Ppency Use Orly) 1
<br /> BUSINESS NAME(Same as futility Name or DBA-f)orhg/thsiness As)
<br /> u)() G Uvs F o cJt�
<br /> BUSINESS SITE ADDRESS 103.
<br /> II. TANK•DESCRU MO. N
<br /> TANKin!! //��^^�� 432. TANK MANUFACTURER 453, TANK CONFIGURATION:THIS TANK IS 434,
<br /> CJel. 3©{�• m O a Vj !L�� ,m i.A STAND-ALONE TANK CmapkdeGm pe6e rm•wel,
<br /> �Y 132-ONE IN A COMPARTMENTED UNIT mmdAmcm in the unh,
<br /> BATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 43G. NUMBER OF COMPARTMENTS IN TI;E UNIT 437.
<br /> M.;T :USE AND CONTENTS,
<br /> TANK USC MIS.MOTOR VEHICLB FEL
<br /> UING O 1b.MARINA FUFS.ING © le_AV IATION FUBLING 439,
<br /> 3.CHTsd4ICnL PRODUCT STORAGE ❑4.I.1A7.ARDOUS WASTE pneumas UW 011) CS 1,EMERGENCY GENERATOR FUEL(SSC§252s j-%e►)
<br /> _
<br /> 6.OTHER GENERATOR FUEL._ © 95.UNKNOWN _ @ 99,OTHER(Speeiry); 439n-
<br /> CQNTENTS PETROLEUM: ❑ ln-REGULAR UNrEnpED © 1c.MIDGRADE UNLEADED lb.PP FNIRTM UNLfiADED
<br /> ❑ 3.DIF.S£1. ❑ 5,JFT FUEL p b"AVIATION GAS
<br /> _ El S,PrTROL£LIM BLEND FUEL ❑9.OTHER PETROLEUM(S!n ): 44tu,
<br /> NON-P?TROLEUM:0 7"U4EDOIL -�` IT!"UMANOT, � - --•"""""'
<br /> ❑ 11,OTHER NON-PETROLEUMS i ); 440b.
<br /> :IV: TANK:CONSTRUMON
<br /> T YPE OF TANK p I.SINGLE M tJ
<br /> 2,DOB1.F WALL L Q 95_UNKNOWN 449.
<br /> PRIMARY CONTAINMENT 0 1,STEEL. 3.FIBERGLASS CI 6.INTERNAL BLADDER u -T�Y��---- AMI.
<br /> Fa 7.STEEL+rNTER4A LtNtIW3 - ❑95.UNKNOWN ❑ 99.0TttER(Spuify): 444m
<br /> SECONDARY CONTAINMENT ❑ 1.STEEL XL3.FIBERGLASS ❑6,EXTERIOR MEMBRANE LINMt ❑ 7.JACKETED 445,
<br /> ❑`�•NONE O 95.UNKNOWN_ ❑99.OTHER(Sp. ; 4454
<br /> LL
<br /> OVERFIiR VEN7'ION 0 1.AUDIBLF&VISUAL AIARMS El2.!BALL FLOAT 3.FILL TUBE SHUT-OFF VArVE -.......
<br /> ..�5z
<br /> 4.TANK MEETS RWIREMENTS FOR FXPMPTION FROM OVER -L PREVENTION EQUIPMENT
<br /> W: PgoDucT I'WASTE PIPING CONSTRU ON
<br /> PIPRVG CONSTRUCTaON ❑ 1.SINGLE WALL IZ 2,DOUBLE WALL ❑99.t7rHrR ra,
<br /> SYSTEM TYPE t.PRESSURE -N�2.GRAVITY _ -- - --- .51
<br /> ..-.. _-_ - ❑ 3.,.CONVENTtONAL SUETION ❑ 4.SAFE SUCTION f 3 CCR 4±63r4,fLli_ s�
<br /> PRIMARY CONTAINMENT ❑ I.STr-E1_ 4,FTBFROLASS ©R.riexlBu [7 10.RIG11DPLASTIC 4647
<br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER ISpecif�): 4W
<br /> SECONDARY CONTAINMENT 0 1.sTr_FI_ 4.FIBERGLASS d S.Fixxmr B (] 10.RIGID PLASTIC -� 46,Ibh
<br /> __ ❑9o,NONe 0 95,UNKNOWN E3 99,OTEI£ (Specify, 4W
<br /> (Speci464c.
<br /> IPI
<br /> PNGnTARTNE CON?ATNMENT SUMP TYPE 1.SINGLE WALL +,&-2.DOURL9 WALL 90.NONE
<br /> VL V rr.'T; APO i.MCO'ERx,.{V"YAND RISES/FM PIPE:PIPING CONSTRUCTION
<br /> VENT PRIMARY CONTAINMENT J9 I.S7[rEL ❑4.FB3L•RGT-ASS ❑ 16.RIGID rLASTIC ❑ 90.NONE ❑99,OTHER(Speeiry): 64
<br /> VENT SECONDARY CONTAINMENT J@ L STEEL ❑ 4-FIBERGLASS O 10,RIGID PLASTIC E) 90.NONE ❑ 99.OTmrR(Speclly): 46tH,
<br /> VR PRIMARY CONTAINMENT ^^0 1•STEEL_ ❑4.FIBERGLASS ❑ 1n,RIGID PLASTIC ❑ go-NONE ❑_99.OTHER S cel 4G4
<br /> ( r IY):
<br /> VR SECONDARYCONTAINMENT Gd 1,STEEL [34.FIBERGLASS ❑ 111,RIGID PLASTIC ❑9D.NONE p 99.OTHr•,R(.�peci(y): 4
<br /> _ -._..t. .. ._ 464bi
<br /> VENT PIPING TRANSITION SUMP TYPE, ❑_1.SINGLE WALL 0 2.MUBLE WALL ❑ 90.NONE _
<br /> RISER PRIMARY CONTAINMENT V I.STFF,L ❑4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑90.NONE ❑99"OTHRit(Specify): OW,"
<br /> RISER SECONDARY CONTAINMENT 1,3TF,E1, ❑ 4,FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90,NONE ❑ 99"OTIIF,(t(Specify): 46411
<br /> FILL COMPONENTS INSTALLED 1,SPB„L RUCKET E3 3_STRIKER PLATVBDnOM PROTECTOR ❑4-CONTAINMENT SUMP a c
<br /> VII: UNDER DISPENSER•CONTAINMENTOm
<br /> CONSTRUCTION TYPE Q 1�5INGrE WALL ❑ 2.DOUBLE WALL _�] 3.NO DMMSERS
<br /> CONSTRUCTION MATERIAL ❑ L STFRL ❑4,FIBERGLASS ($10,RIGID PLASTIC 099.OTtIER(Specify) _ T
<br /> CORAOSION:PRO.TEC T10I .
<br /> STEEL COMPONENT PROTECTION 0 2,SACRIFICIAL ANODE(&) ❑4.IMPRESSED CURRENT 6,ISOLATION 443.
<br /> CERTIFICA710Nt I � ala[ttl(
<br /> at thin UST
<br /> I in im 1 Pn 1 ble with the hamrdone and gbpmd that the W vimtWn pravld tier'tn is tvae,
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<br /> APPLICANT SIGNATURE DATE 470.
<br /> APPLICANT NAME(print) N 0ftl •I (Lft1� 471" APPLICANT TITLE ©W F 473,
<br /> VPCF U5ST 8 Rev.(13/2007).112 www.tmidomarr
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