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Y)NIFIED PRO(;RAM CONSOLIDATED Fu" / <br /> UNDERGROUND STORAGE TANK j I <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION One form oer usT) <br /> TYPE OF ACTION (Chick one Item only. For an UST paument ctostire or removal,complete Only this section and Sections 1,11.111,IV,and IX below) 430 <br /> ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT El �.CHANGE OF INFORMATION <br /> ❑ 6.7EMPORARY UST CLOSURE 7.UST PERNIANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST I ERMANENTL.Y CL•OS$D: 430" DATE EXISTING UST D(SCOVEP-ED; 430n <br /> L FACELITY INFORMATION <br /> FACILITY ID#(agency Use Only) <br /> BUSINESS NAMENamc as FACILITY NA1ME or DBA.Dojng Elus(yPSS A,) <br /> ttU'SLNESS SITE AD SS � 103 CFI'1' i <br /> 164 <br /> II.TANK DESCRIPTION <br /> TONIC ID a, TANK MANtJFACTURJ R ,33 Tq\K CONFIGURATION: THIS TANK LS 434 <br /> ?G-{' �PDl�{w '�, 1 STf�bl%+)''-A STAND-ALDNE TANK <br /> 1 r✓TJ t - ' ONE u.a COMY.�r IMENTCD L1vm. <br /> DATE UST S STEMoicT A f I.ED_ a3s Com lac om c for aach Com annum in r1u unit, <br /> TANK [TY IN GALLONS 436 NUMBER OF COMP TMENITS IN THE UNIT 437 <br /> �C� L <br /> TANK USE la.M070 III TANK USI;AND CONTENTS <br /> R VEHICLE FUELING <br /> ❑ 1b.MARINA FUELING ❑;tc,AVIATION FUELING 43v <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WAS'l-E(lncludn used OU) ❑i5-EMERGENCY GENERATOR FUEL ItiSC ti-526I.5(cy <br /> M 6.OT1iF.R GFX'FRATOR FUEL ❑ 95.UNKNOWN 0 09.OTHER (Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la,REGUI AR UNLEADED ❑ Ic.MIDGRADE UNLEADED �lb.PREMIUM UNLEADED dao <br /> [33.DIESEL ❑ $.JET FUEL, '1 J 6,AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL d 9 nTHER PETROLEuM (g cit) aaua <br /> NON•FE'I'ROLEUM;❑ 7-USED OIL ❑ ]0.ETHANOL <br /> ❑ ]1.OTLiER NON-PETROLEUM $ ci ): Db <br /> IV. TANK CONSTRUCTION <br /> TYPO OF TANK Q 1,SINGLE WALL 2•DOUBLE WALL ❑ 95.UNKNOWN <br /> PRIMARY CONTAINMENT 11 1.STEEL 3.FIBERGLASS 6_INTERNAL BLADDER 443 <br /> 444 <br /> ❑ 7.STEEL+INTERNAL LINING _ a 9$.UNKNOWN F1 99.(ITFTRR (5 ci ); y+ya <br /> SECONDARY CONTAINMENT C) I.JfEL 3.FIBERGLASS ❑ 6.E'(TERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE Q 95.UNKNOWN ❑99.OTHER(S cify): I <br /> OVERFILL PREVENTION 1.AUDIBLE,4r VISUAL 4454 <br /> AL4RMS ❑ 2_$ALL FLOAT <br /> ❑ 3.FILA TUBE StiUT-0FF VALVE 452. <br /> ❑ 4.TANK MEETS REQULRFiMENT$FOR CXEMPTLON FKOM OVERFILL PREVENTION EQUIPMENT <br /> V- PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER <br /> SYSTEM TYPE I-PPISSURE �'? 060 <br /> -CRAVrtY ❑ i CON V1:N'270NAL SUCTION 4.SAFE SUCI ION I23 CCR g2636(a)(3) 456 <br /> PRR>SARY CON'[AINMENT ❑ I.STEEL ❑ d. S.FLEXIBLE ]0.RIGID PLASTIC d6d <br /> ❑ 90.NONE 95-LT1KNOWN ❑ 99.OTHER(Specify), 4644 <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ R.R FXIBLE ❑ tu.R1OLD PLASTIC ;;��; 464�bE 90.NONE E9S.UNKNOWN ❑ 99.OTHER(3pecifV): 464 <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL, ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> • 46dd <br /> VL VENT VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> vFWf PRIMARY CONTAINMENT 1.STEEL 4,FIBERGLASS IO-RIGID PLASTIC ❑ 9p,NONE 99.OTHER(Specify) 464c <br /> PENT SECONDARY CON7AA?.tENT I-STEEL ❑ d.p1BERGLASS Q 10.RIGID PLASTIC dbdcl <br /> ❑ 9[1-NONE ❑ 99.OTHER(Specify) 4641 <br /> VR PRIMARY CON7A1NxENL' 1.STEEL ❑ d.FIBERGLASS 464f1 <br /> ❑ 10.RIGID PLASTIC ❑ 9Q.NONE ❑ 99,OTHER(Specify) 464e <br /> VIZ SECONDARY CONTAINMENT ❑ l.STEEL 4-FIBERGLASS 10,RIGID PLASTIC 99.NONE 99-OTHER(Spec; ) 640 <br /> NTPIPING TRANSITION SUMPTYPG 1.SINGLE WALL 2.DOUBLE WALL ❑ 9p,NONE Ch1 <br /> RISER PRIMARY CONTAINMENT 1.STEEL d,FIBERGLASS 464i❑ 10.RIGID PLASTIC ❑ 94.NONE 99.OTI_ER(Specifyj 464, <br /> FRIIESR SECO14DARYCONIAINME*IT ❑ 1.STEEL 4•FIBERGLASS 10.R1GLD PLASTIC 9o.NnNF 99.OTHfiR(Specify) 4641 <br /> COMPONE JT$INSTALLED 4ti41 1 <br /> 1.SPILL BUCI%ET ❑ 3.STRIKER pLATF/BOTTOIv'PROTE4.CONTAINMENT SUMP 4SIacVII.UNDER DISPENSER CONTAINMENTTRUCnnN TYPE 1.SINGLE wALL 0 2•DOr B r WALL ❑ 3,NO DISPENSERS ❑ 90-NONE 469a <br /> CONSTRUCTION MATERIAL I.STEEL [] 4,FIBERGLASS ❑ 10-RIGID PLAS'FIC ❑ 9%OTHER(S cifv) 4696 c <br /> VIII. CORROSION PROTECTION <br /> STEEL COIWPONENT PROTECTION ❑ 'L SACRIFICIAL ANODE(S) ❑ $.L'vIPRES$ED CURRENT <br /> i 0 6.ISOLATION 448. <br /> GNA <br /> UR. <br /> CERTIFICATION: Z certify <br /> f f at m this <br /> UST Ice i with m cul requirements.W��I.ICANT`S u T�t E U. <br /> hae th <br /> ne te[n[orroatlne provided Lie Is <br /> and inments. eretrue,accurate, <br /> i <br /> APPLICANT SIGNATURE DATE <br /> APPLICANT NAME(print) 471 APPLICANT TITLE a7:. <br /> b c� <br /> UPCF UST-B-L/2 j <br /> 60/80 39Vd 0004 SV9 SNO V 9L9LEE860Z i0:Z0 GOOZ/80/01 <br />