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UNPROGRAM CONSOLIDATED FORIII <br /> DERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFO TION(one fm pa UST) <br /> IYPE OFA ON (Chock.one item only For an UST pe®mant closure orremoval,complete.only this section and Sections L IL III,IV,and IX below) 630 <br /> L NEW�PERMrr ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATR)N -- <br /> 6. RARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 4706 <br /> ATEUSTERMANENTLYCLOSED. - - 470a DATE EXISTMUST DISCOVERM. <br /> L FACILITY INFORMATION <br /> FACILITY(D#(Agency Use Only) - - <br /> BUSMESS NAME(Same as FACB.TTYNAME mDBA-IBumoea As) 3 <br /> JlY>'1C0 lcu CK-? <br /> BUSINESS SITE ADDRESS Im CITYZ007-) <br /> i �� 106 <br /> I�n <br /> IL TANK DESCRIPTIO 4x <br /> TANK#; <br /> 433 TANK MANIJFACCUREt 433 rANRCOxFTGORAI TFnBTANKIS <br /> ❑1.A STAND-AIANETANK <br /> Cg2I'�,, -OxEINAfi M..a IMENIF.II I• <br /> ' t1 M t0(A711 me far«h iv�Ee®o. <br /> DATE USTiSYSTEMINSTALLED 435 TANK ACTTY INGALLONS 436 N[RvIBEROF COMPARTMENTS IN TTS UNIT 637 <br /> :z- <br /> IUL <br /> TANK USE AND CONTENTS <br /> TANK USE ]3 l affMICALEEODUCT STORAGE <br /> ❑ Ih.MARRDDUSWAS - ❑ <br /> Ie.AVIATION FGELiNG - �' <br /> ❑ 3.CF1Eh1[CAL PRODUCT STORAGE ❑4.IlAZARDOT79 WASTEpudRda UudOO) ❑'S: INQt <br /> CYGENATOR FiJEI.(ISC§3528I3(e)I 43% <br /> ❑6.07HERGENERATORFUEL ❑ 95.UEffi4GWN ❑ 99.OTBE.OTEIER k dao <br /> CONTENT PETROLEUM ❑I&REGULARUNLEALtID ❑ te.MIDGRADEl)14I.EADID IIe YRE1EIJMl7NLEAD® <br /> 03.DIESEI. 135.IEI FUEL 6.AVIATION GAS 446 <br /> ❑ 8.PEiROLEUMBLFND FUEL ❑.9.01'HIItpETROLEC3M <br /> NON-PERtOLEUM ❑ 7.USED OIL 10.ETHANOL - aaon <br /> ❑ 11.OTf�RNON-PE[ROLEUM(S <br /> IV. TANK CONSTRUCTION <br /> TYPEOFI ❑1.SINGLEWAU. 7 DOUBLE WALL 95.t)NR4lOwB 444 <br /> PREMARY AINMENT I.51ffi Ll 3.FMEFt ASS [36.ENTBRNAT-7+3 anncR <br /> aaa <br /> ❑ 7.S7FII.+7NTEIO4ALI.E4II4G ❑ 95.UNKNOWN ❑ 99 OTHER ( Y- ass <br /> SECONDARYCOMADAffi41' L STEEL. ❑3:FIEERGL ASS ❑6.EXIERiDRAffAIDRANE LRJEIt ❑ 7-JACKETED � <br /> rT 90.NONE ❑ 95.UNKNOWN ❑99 O'il�ddt k - 4n <br /> VERFB.L FILL TUBE SIIUL-Utr V�v� <br /> FREVENIION - ' ( 1.Al1DIBLEEnREQLALARMS. FOPE)MMPnONFFROMOVFRCHT pREVENTION[9�UIPMENT <br /> Ll 4.TANKMEEtS REQUIRE ffidTS <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION 4a <br /> PIPING CA STRUCTION ❑L SINGLfrwALLID 2 DOIr WALLED ❑99.GnIFR ua <br /> PIPINGSYS <br /> 1PR�SSURE. ❑ 2GRAViTY ❑3-CONVENTIONAL.st=ON. Q 4.SAFESUCIIONf23I.CR¢2636(s ) 964 <br /> PRUTARYCONTAINI - `❑ 1:STFEL 4.FIBERGLASS El& LE aBLE Q lO.RIGm PT.ASTIC <br /> 466a <br /> 0 9D . 095.tMKNOWN ❑99. <br /> 0114 LP - ❑ to.RIGID PLASTIC <br /> SECONDARY CONTAINMENT ❑'1..STEEL. 4.FIDERGLASS ❑& d5ac <br /> ❑ 91 ❑ 95.UNKNOWN ❑99.OTHBR( ) 46W <br /> PIPING(CURBINE OONrAINMENrsumpTyrE I,SB.WT,EWALL ❑-DOUBL.EWALL ❑9R NONE <br /> x VL VENT,VAPOR RECOVERY(VR)AND RLSER/FI[L PIPE PIPING CONSTRUCTION d6a� <br /> VwPmmRY COMAE4NI I.STEEP: 4.FIBIItr.- ❑ 10.RIGm PLASTTc ❑ 90.NONE 99.OTHER(SPedly) � <br /> 464f <br /> VENT SECONDARY COMAtNMEM ❑ LSTEEL 4.FIBERGLASS 10.RIGID PLASIIC 90.NONE 93.OTFIDL(SP�SY) a64Fl <br /> 4646 <br /> VRPRAIARYCOMAIIdMENf ❑ 1:STEF3. 4.EtBIItGIASS HIRIGIDPLASTIC ❑9o.NONE 99.OTHER464 <br /> (SpedfY) <br /> 466 <br /> W <br /> VRSECO YCONrAINIENT LSTEEL. 4.FIBERGLASS 70.RIGID PIASTLC 90.NDNE 99.OTE$Tt(SpxifY) 4661 <br /> dH <br /> - VENTPIFING3RANSTTIQA`SiRdl'7YPE I.SINCdE WALL IQ.RIGBLEWALL -90.NONE Wi <br /> . <br /> R19MPRIM y ONTA 412011' 1.STEEL ❑4.FBERGLASS lo.RIGIDPLASIIC ❑ 90.NONE 99.OTHER(SP .1 <br /> 70.RIGIDPGASIIC 90.NONE 13 99.OTHER <br /> a66 <br /> RISER S( NDARYCONTAINMEM 1.STEEL. ❑4-FIBERGLASS d64k1 <br /> FIrT.COMPONENTS INSIAI.LED i.Sp7LL BUCICEI i- ,3.SIRi;I is 1!:ATFJBOTIOMPROTECTOR. ❑4.CONTAIN Si7MP <br /> d51ac <br /> VIE UNDERIiISPENSER CONTAINMENT(IJAC) 46, <br /> CONSTRUC7LONTYPE. . 11L <br /> MATERIAL <br /> ❑2D EnEWALL ❑.3.N0DJSPENSFSTS - ❑90.NONE 461 <br /> CONS7RUCRON MATERIAL ❑ I.STEQ: D 4.Flg¢tGLASS ❑ lA ItiGIDPLASTTC ❑99.OTAFR S ) . <br /> VIII. CORROSION PROTECTION ana <br /> STEEL COMPONENT PROTECTION <br /> > SACRRTCIAL pNIAE(S) ❑ 4.IMPRE MCURRENT &ISOLATION <br /> IS. APPLICANT SIGNATURE <br /> CRRTIFICATION:.1 eertdy that this UST system is comp■tihle with the hsaeRZ seemtavte stored sad that the iaformatias provided herein is tire4 acenrate, <br /> sad iafdl co Raom with I 4R1: <br /> DATE r <br /> nL APPLICANT TITLE <br /> APPLICA'NTNAME(PrIDt) <br /> Rev.(12(2007) <br /> UPI UST-B-V2 <br />