BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM I /- 11 �/ UNDERGROUND STORAGE TANK ("( OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYP FACTION (Check one item only. For an UST permanent closure or removal, complete only this section and S 70- I, II, III, IV, and IX below) 430 NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE El 7. UST PERMANENT CLOSURE ON SITE 0 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 411'a I DATE EXISTING UST DISCOVERED: 4306 I. FACILI'T'Y INFORMATION FACILITY ID # (Agency Use Onty) (Y B INESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 BUSINESS SIT -,ADDRESS 105 �� n CITYtot ��ktol�% a-v✓�� IL TANK DESCRIPTION TANK ID d / p l 7 .C� q 432 /7 TANK MANUFACTURER 433 AG. ]Complaimom TANK CONFIGURATION: THIS TANK is 434 ❑ 1. A SMAND-ANE TANK 6xE IN A COMPARTMENTED UNIT. pqp for emcb compmawa mthe aeit. DATE USI;JYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 433 IIL TANK USEAND CONTENTS TANK USE ❑ la MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (bdades Used 00) ❑ 5_PdERGENCY GENERATOR FUEL (BSC VM I.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN . OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ It REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM 440a NON -PETROLEUM: ❑ 7. 1 MW OIL ❑ 10. ETHANOL 1.OTHER NON -PETROLEUMS ' ): 4406 TANK CONSTRUCTION TYPE OF TANK ❑ 1. NNGLE WALL LFL DOUBLE WALL Q 95. UNKNOWN 443 PRIMARY CONTAINMENT . STEEL 0 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ OTHER S 444a SECONDARY CONTAINMENT STEEL ❑ 3. FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LAVER 7. JACKETED 445 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER ( ): 445a OVERFILL PREVENTION 1. BLE & VISUAL ALARMS 2 BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452. TANK MEETS REQUIREMENT'S FOR EXEMPTION FROM OVERFILL PREVENTION EQUBMENr V. PRODUCT ! WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION M<SIVGLE-WALLED 13 7- DOUBLE -WALLED 1`199. OTHER 460 SYSTEM TYPE URE 2 GRAVITY Q 3. CONVENTIONAL SUCTION 4. SAFE SUCTION , CCR F26WaX3)I 458 PRIMARY CONTAR04ENT . STEEL 0 4. FIBERGLASS ❑ 8. FLE7t3BLE 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHERCS ): 46ta SECONDARY CONTAINMENT ❑ 1. STEEL 0 4. FIBERGLASS ❑ 8. FLEXIBLE 0 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN A 99. OTHER (Specify): , .c ,te Le"Az-�L464e PIPING/TURBINE CONTAINMENT SUMP TYPE 1. SINGLE WALL Q 2. DOUBLE WALL Q 90. NONE 464d V1= VENT, VAPOR OVERY");AND RISER/ FHL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT WI. STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE El 99. OTHER (Specify) 464e VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE C1 99. OTHER (Specify) 464f VR PRIMARY CONTAINMENT 0 I. STEEL E3 4. FIBERGLASS 0 10. RIGID PLASTIC 90. NONE 99.OTHER (Specify) 4648 VR SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 099.OTHER (Specify) 464h 464hi VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 2. DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT U 1. STEEL 0 4. FIBERGLASS I0. RIGIDPLASTIC 0 90. NONE El99.OTHER (Spa*) 464j 461't RISER SECONDARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE C1 99. OTHER (Specify) 464k 4641 FILL COMPONENTS INSTALLED C1 I. SPILL BUCKET 0 3. STRIKER PLATVBOITOM PROTECTOR Q 4. CONTAINMENT SUMP 451ac VII. UNDER DISPENSER'CONTAINMENT- f UDC).. CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ L DOUBLE WALL ❑ 3. NO DISPENSERS ONE 469* CONSTRUCTION MATERIAL 0 L STEEL 0 4. FIBERGLASS 80. RIGID PLASTIC ❑ 99.OTHER (Specify) 469bc VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT J4 6. ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that tbb UST system h compatible wiw the hazardous substance stored aad that the informatlon provided bereln is tree, accurate, and Ia fall oo Baaee with legal requirements. APPLICANT SIGNATURE ' DATE 470• \ � • -Z �i . C iy APPLICANT NAME (print) (� z 471' APPLICANT TITLE 477- UPCF UST -8 -1/2 Rev. (12/2(107)