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� 05208�5
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUNDSTORAGETANK
<br /> OPERATING PERMIT APPLICATION - TANK INFORMATION one form per UsT)
<br /> TYPE OF ACTION (Check one item only. For an UST permanent elosim: or removal, complete only this section and Sections L R. Rl, IV, and IX below) Oso
<br /> 1. NEW PERMIT ❑ 3, RENEWAL PERMIT S. CHANGE OF INFORMATION
<br /> 6. TEMPORARYUST CLOSURE ❑ 7, UST PERMANENT CLOSURE ON SITE 8, UST REMOVAL
<br /> DATE UST PERMANENTLY CLOSED: O 430° DATE EXISTING UST DISCOVERED: 4306
<br /> I. FACILITY INFORMATION
<br /> FACILITY ID N (Agency Use Only) I
<br /> BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3
<br /> BUSINESS SITE ADDRESS 103 CITY 104
<br /> II. TANK DESCRIPTION
<br /> TANK IDN 432 TANK MANUFACTURER 433 TANKCONFIGURATION: TIBSTANK IS 4M
<br /> 0J& 1 , A STAND-ALONE TANK
<br /> [12. ONE MA COMPARTMENTED UNIT .
<br /> Commete am mce for tin tbeunit
<br /> RATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENT'S IN THE UNIT 437
<br /> III. TANK USE AND CONTENTS
<br /> TANKUSE 0 Is. MOTORVEHICLEFUELING D MMARINAFUELING 0 la, AVIATION FUELING 439
<br /> 11 3, CHEMICAL PRODUCT STORAGE 4. HAZARDOUS WASTE Ondudee Used Oil) 05. EMERGENCYOENEAATORFUELMSC 6252BI,s(eB
<br /> 0 6. OTHER GENERATORFUEL 95. UNKNOWN 0 99, OTHER (specify): 43%
<br /> CONTENTS PETROLEUM: 0 Is. REGULAR UNLEADED D to, MIDGRADE UNLEADED D Ib, PREMIUM UNLEADED me
<br /> D 3, DIESEL 5. JETFUEL U 6. AVIATION GAS
<br /> 0 S. PETROLEUMBLEND FUEL 9, OTHER PETROLEUM (specify): 440°
<br /> NON-PETROLEUM: 0 7. USED OIL 0 10, ETHANOL
<br /> 1. OTHER NON-PETROLEUM IS mitt, Mob
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OF TANK I. STNOLEWALL E12. DOUBLEWALL 095. UNKNOWN 443
<br /> PRIMARY CONTAINMENT jff 1, STEEL D 3, FIBERGLASS 0 6. INTERNAL BLADDER 444
<br /> 0 7, STEEL+ INTERNAL LINING ❑ 95. UNKNOWN , ❑ MOTHER eci ): aa4s
<br /> SECONDARY CONTAINMENT 0 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER D 7. JACKETED 445
<br /> ❑ ", NONE D 95. UNKNOWN 92 THE
<br /> OVERFILLPREVENTION 1, AUDIBLE &VISUAL ALARMS 2. BALI, FLOAT 3. FILL TUBE SHUFLOFF VALVE 652
<br /> IN 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILLPREVENTION EQUIPMENT
<br /> V. PRODUCT / WASTE PIPING CONSTRUCTION
<br /> PIPING CONSTRUCTION 01. SINGLE-WALLED 02, DOUBLE-WALLED El99, OTHER 460
<br /> SYSTEMTYPE D I. PRESSURE E 2, GRAVITY 0 3, CONVENTIONAL SUCTION U 4. SAFESUCTION 23CCR62636(a)(3)) 458
<br /> PRIMARY CONTAINMENT 0 LSTEEL 0 4, FIBERGLASS 0a. PLEXIBLE D ID. RIGIDPLASTTC 464
<br /> LK 90, NONE 0 95, UNKNOWN D 99. OTHER(Specify): 464s
<br /> SECONDARY CONTAINMENT 0 L STEEL D 4, FIBERGLASS 0 8. FLEXIBLE 0 10, RIGID PLASTIC 4Mb
<br /> 0 90. NONE D 95, UNKNOWN 0 99. OTHER (Specify): 464c
<br /> PIPINGrI'URBINECONTAINMENTSUMP TYPE D1, SINGLE WALL F2 TDOUBLEWALL a' 90. NONE AlUd
<br /> VL VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br /> VENT PRIMARY CONTAINMENT 0 1, STEEL 0 4, FIBERGLASS D 10, RIGID PLASTIC 2 90. NONE D 99, OTHER (Specify) 4646
<br /> 46461
<br /> VENT SECONDARY CONTAINMENT D 1, STEEL D 4, FIBERGLASS D IO, RIGIDPLASTIC M 90, NONE D 99. OTHER (Specify) 464f
<br /> 4640
<br /> VR PRIMARY CONTAINMENT ❑ 1, STEEL Ll 4. FIBERGLASS 10. AIGID PLASTIC 0 90. NONE 99. OTHER (Specify) 4648
<br /> 464191
<br /> VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 6 90. NONE ❑ 997THER(Spmity) 469h
<br /> 461h1
<br /> VENT PIPING TRANSITION SUMP TYPE 0 1. SINGLEWALL ❑ 2. DOUBLE WALL 90. NONE 4641.
<br /> RISER PRIMARY CONTAINMENT 1, STEEL 4. FIBERGLASS 10. RIGIDPLASTIC N 90, NONE D 99. 07HER (Speafty) 464)
<br /> 464'1
<br /> RISER SECONDARY CONTAINMENT I. STEEL 0 4, FIBERGLASS D 10, RIGID PLASTIC IN 90. NONE 099. OTHER (Specify) 464k
<br /> 464k1
<br /> FILL COMPONENTS INSTALLED ❑ I. SPILL BUCKET ❑ 3. STRIKER PLATFIBOTTOM PROTECTOR 4, CONTAINMENT SUMP 451ec
<br /> VII. UNDER DISPENSER CONTAINMENT (UDC)
<br /> CONSTRUCTION TYPE 0 1 , SINGLE WALL D 2, DOUBLE WALL D 3, NO DISPENSERS 19 90. NONE 4694
<br /> CONSTRUCTION MATERIAL ❑ I , STEEL El 4, EIBERGLASS 0 10, RIGID PLASTIC 0 99, OTHER (Specify) 469bc
<br /> VIII. CORROSION PROTECTION
<br /> STEEL COMPONENT PROTECTION CRIFICIAL ANODE(S) 04. IMPRESSED CURRENT 06. ISOLATION M6,
<br /> IX. APPLICANT SIGNATURE
<br /> CERTIFICATION: jCfttTth&t th UST stem is compatible with the hazardous substance stored and that the inforroation provided herein Is true, accumty
<br /> and to II tom li lth fecal reouirements.
<br /> APPLIC SIGN DATE 470,
<br /> PPLICANT nt) \.n .gyp -•,, .fa / 471• APPLICAN�T>;CI 4n•
<br /> UPCF UST-B - 12 1"�C.�(� C�-Cid\ I,r Rev. (12/2007)
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