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07/10/2009 10:34 2098585066 TWO GUYS FOOD PAGE 08/08
<br /> UNIT I M PROGRAM CONSOLIDATED k'ORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION--TANK INFORMATION (One form pct UM
<br /> TYPE_OF ACTION 7=7 one ircm ori/i. For a UST Admire or Pemoml,complelr.only Nfis section and Sed/ions L 11.111.R!and LCbe/owj 4,111
<br /> © 1.NEW PERMM' ❑ 3.RENEWAL PERMIT 10 5,CHANGE OF INFORMATION
<br /> Cl 6,TL•MPORARY UST CLOSURE © 7.UST PERMANENT CLOSURL•ON SIT'F, 171 S.UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: 439y 1 DATE.EXISTING UST DISCOVERED: 43DIL
<br /> Ir.;�FACIL .IMORMAT[ON ..
<br /> FACILITY ID'#(Agency U,at Only) 1 1
<br /> _1 r L
<br /> BUSINESS NAME(.Same os Faei(i(v Name or DRA-Doing ihmsiacss As) 3.
<br /> - zwO &01-s oO J L-
<br /> 11USINE.S,SITE ADDRESS ro3. CI'T'Y 104,
<br /> I.L TANK bESCRIPTION
<br /> TANK ID 0 4•z TANK MANUFAC'T'URER as}• TANK CONFIGURATION:IS TANK IS
<br /> 434.
<br /> T R O1 �J{ 11 FA� rYlopE 7 We L.D IA1[y- 1z.ONSTAND-ALONE
<br /> IN NA COMPARTMENTED UNIT C�raothemflach
<br /> t,
<br /> DATE UST SYSTEM INSTALLED 43-1- TANK CAPACITY IN GALLONS a36, NUMBER OF COMPARTMENTS IN THE UNIT 437.
<br /> '�. D •$`) 1(� OHO
<br /> TAS:u g AND S:ONTFNTS
<br /> TANK USE JR In.MOTOR.VEHICLE FUELING p lb.MARINA FUELING ❑ le.AVIATION FUELINO 439.
<br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Mdtd.tT,.d1x1) (3 S.L-.wi ISROENC Y GENERATOR FUEL Iit,SC ISISI.5(c)1
<br /> __ TEL36.OTHER OENERATOR Fi,1RL. . ❑ 95.UNKNOWN_ _ _ Q 99,OTHER(Specify): 439a
<br /> CONNTS PETROLEUM- Ia.REGULAR UNLEADED [1 MIDORnbE UNIpADEO 11 lb.PRT3MLUM UNLtADT;D 440.
<br /> 3.DIESEL. ❑S--TET FUEL ❑ 6•AVIATION GAS
<br /> R.PETROLEUM BLEND FUEL ❑9.OTHER PETROL um(mt5 c�yf);� 410%
<br /> NON-PTiTROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL
<br /> 0 1.1.OTHER NON-PETROLEUM(Specify): 440b.
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OF TANK_ ❑ )-SINGLE WALL [ 2.DOUBLE.WALL ❑95.UNKNOtYN 445.
<br /> �..-..1..1..w... . ---- -�..,.-w.,__.-.
<br /> PRIMARY CONTAINMENT -1,STEEL R 3.FIBERGLASS ©6.INTERNAL BLADDER 444.
<br /> ❑ 7.STEEL+INTERNAL LINING - E3 95.UNICNOWN (3 99.0TiiER(SFccify); 4441
<br /> SECONDARY CONTAINMENT ❑ 1.STF,91, Jb3.xIBERGI„ASS (j 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445.
<br /> ❑90.NONE _ ❑ 95.UNKNOWN�1 1 11_❑99.OTHER(Specity): 445m
<br /> OVERFILL PREVF,'NTTON ❑ t.AUDIBLE&VISUAL ALARMS ❑2 BALL FLOAT SO 3.FILL TURF SH[fI'-0FF VALVE
<br /> 4-t❑4.TANK MEETS REQUIREMENTS FOR EREMMON FROM OV$RI`141,PREVENTION EQUIPMENT
<br /> R-ASTE PIPING'CO.1iiSJCTION
<br /> PIPING CONSTRUCTION q 1.SINGLE WALL ja 2.DOUBLE WALL p 99.OTHER,_ _ 4A.
<br /> SY
<br /> _ STEM TYPE _ ' �W t, r;P tisssu eu.ORAVIIY �1.CONVENTIONAL SUCTION Q .SSAPE SUCTION(23 CCR Az��(,J� -458.
<br /> PRIMARY CONTAINMENT ❑ 1.STRRL 19 4,FIBERGLASS ©S.FLEXIBLE p�10.RIGID PLASTIC 464.
<br /> 90,NONE ❑ 95,UNKNOWN 13 99.GIBER(Specify): _ 4Gtn
<br /> SECONDARY CONTAINMENT © t.STrFL ,S 4.FIBEROLA53 11 R,FR,FLEXIBLE 10.RIGID PLASTIC w 4Mh
<br /> --_-�1,.. ._ F-190.NONE -© 95.UNKNOWN � 11 99.OTHER(Sp ffjr� 464a
<br /> Pf('INGITUREINF,CONTAINMENT SUMP TYPE 'Z1.SINGLE WALL LI 2,DOUBLE WALL )] 90.NONE - - 464d,
<br /> Vi. VENT;V CO ERX.( R},ANA RISER YML PZPE:PIPYNG 0NSTRUCu. ON
<br /> _VF_Nf PRIMARY CONTAINMENT )M t.STEEL ❑ 4.F7BERaLASS ❑ 10,RIGID PLASTIC ❑ 90•NONE ❑ 99-("ER(Spediy)• r�0e
<br /> 464el.
<br /> VENT SECONDARY CONTAINMENT ,;9 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLAsTic ❑ 9o.NONE ❑99.OluER(SPedry)- vwr-
<br /> 461Ii
<br /> VVR PRIMARY CONTAINMENT _ 15�1-,STEEL.--�_114.F10I:R_GLASS ❑ 10.RIGID PLASTIC ❑_ 90-NONR ❑ ". .OTHER(SpL i'Sy):� 04
<br /> VR SECONDARY CONTAINMENT w 1.STS[ -❑ 4.F1RtGLASS © I0.RIGID PLASTIC ❑ 90,NONE ❑99.OTtiFR(Specify) �,Oft
<br /> qFt
<br /> VENT'PIPING_TRANSITION SUMP TYPE w_C3 1.SINGLE WALL I(2,DOUBLE WALL ❑90.NONE�14641.
<br /> -
<br /> RISER PRIMARY CONTAINMENT J&I,STEEI, I] 4,FIBERGLASS ❑ ID-RIGID PLASTIC ❑ 90.NONE .D.99.OTHER(specify): a�Fil,
<br /> RISER SECONDARY CONTAINMENT AI.5TEL•L [] 4,FIBERGLASS ❑ t0,RIG)D PLASTIC ❑ 90.NONE 0 99.OTHER(Specify)-. a 1
<br /> 641
<br /> FELL COMPONENTS INSTALLED ga-i.spiLi,nUCKET ❑3.STRIKER PLATEIBOTTOM PROTECTOR ❑4.CONTAWMF-N'r SUMP
<br /> UND�EItD!YSIyE 3SER CON--T,�N-T(EJDC)
<br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL ?,DOUBLE WALL 3.NO DISFEN$ER$ 90 NONE
<br /> CONSTRUCTION MATERIAL ❑ i.$•TEFL ©4.FIBERGLASS p 10.RIGID PLASTIC ❑ 99-OTHER($pcdfy) 4(
<br /> ''VIIX.. CORROSION PROTECTA!0
<br /> STEEL COMPONENT,'FROTEMON ❑2.SACRIFICIAL ANODES ❑4.IMPRESSED CURRENT 6.ISOLATION °q8
<br /> Ix APEIJICANT'SIGNATURE:` " •
<br /> CEWnFICAlnON:I certify that this UST Is colmPpdble with the hexardons sub-Stsirce stared and that the inA►rmstion provided herein
<br /> accurateand In.fall eom with I I altemente.
<br /> APPLICANT SIGNATURE / DATE 470.
<br /> APPLICANT NAM£(print) 1j A IL K j,y"6 471. APPLICANT TITLE Q W A)/�'� 172-
<br /> UPCF UST-13 Rev.(12/2007)-1/2�1 www.00idomerB I�
<br />
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