BILLING - Laserfiche WebLink

Home Browse Search

/1 UNIFIED PROGRAM CONSOLIDATED FORM E: UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per uST) TYPE OF ACTION (Check one item only_ For an UST permanent closure or removal,complete only this section and Sections I,II,III,TV,and TX below) 4 I.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION I ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED_ a3ob r L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ f ^ 1 ', BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 C= 104 �i? - 1 U.TANK DESCRIPTION TANI�jI2 � 432 TANK MANUFACTURER 433 TANK CAC)NtZGURATION: THIS TANK 1S 434 r� R1.A STAND-ALONE TANK Comp❑2.ONE IN A COMPARTMEtiTED UNIT. 3ctc t fat cacti cnt in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACTTYQj GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 IV Le L�c J-t M.TANK USE AND CONTENTS TANK USE ❑ 1a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ 1c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lvclodcs Uv d 00) ❑ 5.EMERGENCY GENERATOR FUEL(HSC¢25281-5(d) ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN a 99.OTHER (Specify): G"Tt - : .a 434n CONTENTS PETROLEUM_ ❑ la.REGULAR UNLEADED ❑ Ic.MIDCRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GP ❑ 8_PETROLEUM BLEND FUEL ® 9.OTHER PETROLEUM ( t40a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 44ob 1 I.OTR NON-PETROLEUM(S ): HE IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UN MOWN 443 PRIMARY CONTAINMENT _&I I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95_UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRAFFE L 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(S (�,l"T 445. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3_FILL TUBE SHUT-OFF VALVE 452. ®'4-TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION N 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ElI GRAVITY N 3-CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL. ❑ 4.FIBERGLASS U 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1_STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95_UNKNOWN ❑ 99-OTHER(Specify): 464` PLPINGrFURBLNE CONTAINMENT SUMP TYPE ❑ 1_SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ TO_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464c1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10-RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4648 464gl VR SECONDARY CONTAINMENT ❑ 1.STFF), 4-FIBERGLASS ❑ 10_RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464b 464hI VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL. ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify) 4641 464 i RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑4_FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99-OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTrOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is true,accurate, and in full complimce with legal requirements APPLICANT SIGNATURE ; DATE azo. a72. 471. APPLICANT TITLE APPLICANT NAME(print) UPCF UST-B-1/2 Rev.(12/2007)