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Jun 18 08 06:53p Allen Thomas 530-622-2275 p.12 <br /> OF � N f:;�)kL kAASn o_k) . <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(Oae Tetm per urM <br /> TYPE OF ACTION (Click one item ody. Form UST Pelrt RWO cl9gus or scmD9a1 wmpWetady the section and Secuom(,IL B(,N,end IX below) 430 <br /> Q 1.NEW PERMIT Q 3.RENEWALPERMIT 5.CHANGE OF INFORMAT(ONa�2.. -Aye <br /> 6-TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.USA REMOVAL <br /> DATE USF PERMANENTLY CLOSED. �' DATE F�TSTB4G UST DISCOVERED: M3A <br /> L FACIIdTYINFORMATION.; <br /> FACILITY TDH(Agmry Use ONyl - <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Dpmg Bu�rss At) - <br /> D•91 s G% Lt L-",t_ <br /> BUSINESS SITE ADDRESS to I (3(Y <br /> II.TANKDFSCRWnON. <br /> TANK mff a3J TANK <br /> MANUFACTURER 4B TANKCONFKRIRATIOW TWSTAWtS 04 <br /> ( 0 L ASTwND-wr.Wm Tw <br /> � ( -S��'- . aJ�vrw cnr�wsTMENtIDtJNtr. <br /> DATE UST SYSTEM BJSfALLED 4u TA�fK CAPACITY M GAIIONS NUMBER OF ODMPARTMENTS INTBE UNIT 43r <br /> III-TANK USBANDCONTENTS' :'..: <br /> TANK USE a MOTOR VEHICLE FUELING ❑ Ib.MARINAFumjma ❑ lc AVJATRBJFUELPI 4]9 <br /> 3.CHEm1CALPROIXJCTSTORAGE ©4.HAZARDOLLSWASTS(edaduU ,,) ❑ 5.EMFRGENCYGENFRATORFUFLPIClam LX01 <br /> ❑6-OTHER GENERATOR FUEL O 9S.UNXNOWN <br /> [I 99.OITlER(S k 4194 <br /> CONTENTS PETROLEl1M: ❑ 1 .REGULAR UNLEADED ❑ le.MmoRADEUNLEADED ❑ 1b.PRFMRIMONLPADED 4a <br /> 3.D16SEL ❑ S.JET FUEL Q 6.AVIATIONGAS <br /> S.PETROLEUM BLEND FUEL ❑ 9.OTHER PSIROLEUM - s4lti <br /> NOMPEIROLEUM: 7.USEDOIL ❑ 10.EnTAN01. <br /> 011.0T7ff3t NON-PETROLEUM 4sR <br /> IW TANKCON_STR�GIION. <br /> TYPEOFTANK ❑ LSINfiI.E WALL 2DOUBl31 WAtiL 95.UNKNO9M 4y <br /> PRIMARY CONTAD MEN T ❑ 1.STEEL 3.FIRr,INTERNAL <br /> (] 7 STEEL.*IN'[77WALfLADDER <br /> XfNG . ❑95.UNKNOWNB Q 99,Drum IS 444 <br /> SECONDARY CONPAINMENC Q LSTEEL 3.FIBERGLASS Q 6.EKhRioRb4ExBFtANE TER ❑ 7. WLVF <br /> ty❑90.NONE 95.UNKNOWN ❑99.OTHEROVERFILL PREYENI10N LAUDIBLEa:VL4UALALARMS 2BALLPLOM 3F71LTUSE SNUTOFFs2QUQUDAENM FOR ID(FLlpnoNFROM OVERFILL PREVETO'ION IDpMEODUCT/WASIEPEMGCONSMIve ION PIPINGDGUBLE-wALt�D 9y. .SYSTEM TYPE LPRESSURE 2G14AVTIY 3.OW7VFMIONAL SUCTION 4.SAFESUle CKBPRGIASS RFLEI®LE JO.RIOID P4❑ 90.NONEQ95.UNKNOWN ❑ sSECONDARY CONTARQIE.N7' ❑ LSIEFT• 4.F3�0.GLAS5 RFT�LE Q WRWM I4690.NONE []9S. ❑99.OTNEPr <br /> PIPING/?UlURNE CONTAINMENT SUMP TYPE .sINGiP WALL z DOf1HLB wALL W.NONH 4ty <br /> VI.VENT,VAP,OR.RECOVERY�(VR)AND RISER/FiLiir•PDE;YIpING CIA ON <br /> VENT PRDIARY CONTAINMEM I.SLEET. 4.FWERGIASS IO.RFGIDPJASTK SO.NONE 99.OFF[EREH))) <br /> 46rVENTSECONDARYCONTAtNt4ENf IS41:EL 4FB .cS 10.RwtDPLASIYC 90.NONE 99.OlIgR 464LVRPR]MARYCONTA(NMFM LSTEFL 10.RIGID PLASTIC 9R NONE99.OTFIER 46taVRSECONDARYC7 PLASTIC NE99 ¢R IS ) eslp <br /> VENT PWMG TRAPbI'f10N5UMP ME I.SINGUi WAIL 46nI <br /> 2 DOIIBL.E WALL. 9d NONE 46y. <br /> R6F3t PRIMARY NNTAD0.IL324T' 1.S1TiE7. 4.F'®ERGLA,S 10.RIGID PLASI'{C 90.NOtg 99.00�IL(Spcify) Mai <br /> JUSFR SECONDARY CONTAII.M1.IENi' I.STEEJ. 4.FIBERGLASS JO.RIGID PLASTIC 90.NONE 99.OTI�![(Spmfy) 1a64k <br /> FILL COMPONENTS INSTALLED I.SPR3.BUCKET U3.STRDURPLATFA3OTrom PLOJTFLTOR 4.CONTAINJ@iTSU[� 451aa <br /> VIL UNDER DISPENSER"EONTAINMENT,lpp ). <br /> CONSLRUCTION'IYPE .SINGLE WALL Q 2000BIF WALL ❑ 3.NO DISPENSERS Q 90.NONE 469+ <br /> CONSTRUCTION MATERIAL I.STEEL ❑ 4.FMERGLASS ❑ IO.RLOID PLASTIC 99-OTIM( ) 4614c <br /> VIIL CORROSION-PROTECTION`` <br /> STEEL COMPONENT PROTECTION .❑ L SACRIPfCIALANODE(S) ❑4.D4PRL+ ED CURRENT Q &ISOLAITON 40. <br /> Ili APPLICANTSIGNATURE_ <br /> CERTFFICATION: I certify Cut dab U57 sTMID is COapaHble with the hazarde"mbJb mcc stored aad tlut the information provided heeea is n e,seemale, <br /> and In inn con wNh a!requfemeatr. <br /> APPLICANT SIGNATU DATE 6 �`arj axo. <br /> APPLICANT NAME(priest) APP[.1CANT TITLE J +r <br /> UPCF UST-B-T/Z <br /> Rev(V120071 <br />