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Nov 23 09 09: 55a RAVINDERSINGH 209 4756 p. 3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK atliL <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One F.pC U <br /> TYPfi OF ACTION (Chat ooc item only. For m UST pIBCWHISII clollse oT Tom A comOde 0*NisaR��(1p/R and SetTiom 1.IL TIL N,and IX below) 00 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT Ly�J.CHANGE OF INFORMATION <br /> El (L TEMPORARY UST CLOSURE Ll T.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: °10' DATE E=ING UST DISCOVERED: °I0b <br /> )L PACILHY 114FORMATION <br /> FACILITY N#(Agm Y Use UfilY) <br /> BUSH S NAME(Samem FACR.RY NAM4 oe DHA-Dam$Buaineae Aa) s <br /> G /7�l/.7-�i- GJ/g j/fl�.t�0/r- <br /> 6US eFSp DDRESS ` im CITY ,574CK7o/// Ia <br /> IL TANK DESCRIYITON <br /> TANKID# n TANXIWANUF MMEX. •U ITAI%MNRGURA�. TIUSTANKIS )' <br /> _/ SK ASTANfnWN6Tn NK <br /> Q7 own AC mrAxTMENTEn UNIT. <br /> Oa0 RT wlhcviL <br /> DATE UST SYSTEM INSTALLED <br /> Q's TANK CAYACTIY Q4 GALLONS 4 NLIMBER OF COMPARTMENT'S IFC TILE UNEP 111 <br /> za <br /> IEC:TANKU99"D CONTENTS <br /> TANK USE WE MOTOR VEFRCLE HER Ih MARINA FUEUNO ❑ I ,AVIATION FUELINO 479 <br /> Q 3.CHEMICAL PRODUCTSTORAGE 0 4.RAZARDOUS WASTE(6d Atr lldalI Q 5.E34ERGE4L-fOENeRATORPUELp4C473 I-Ne)j <br /> ❑6.OTHERGENEMTORFUM Q 95.UNKNOWN Q 99.OTHER 419a <br /> CONTENTS PETRoIEUM: 0� 1}}REGULAR UMXADED E310.MIDORADEUNLEADED Ib.PREMIUM UNLEADED61I <br /> �7.DIBSEL 0 5.JhTFUf:L 6,AVIATION GAS <br /> 0 SPGTROIXOMBLEND FUEL 0 9.OTHER PETROLEUM a1h <br /> NOWPETROLEUM:0 T.USEDOa io.MLZDL <br /> I I.OTHER NoNYETROLEUM aeoS <br /> IV. TAWCONSTRUC.TION - <br /> TYW..OFTANK 'WULl WALL T UOLEW.W. 95. OWN NI <br /> PRIMARY CONTAINMENT OVI.STEEL L3 1,MpIUjL4R% L1&INTE NAL W-AWIP, W <br /> aIT >.STRISLr INTERNAL LINTIW3 93.rIaKNOWN 99.OTNER Is aee <br /> NL'CONDARY CONTAINMENT u 1.SZE[L tFIHkRULA?N ntulnrtWR McMI1RAryfi LINER .CACICETED w <br /> 0 W.NONE 0 95.UNKNOWN 99.OTHER <br /> OVE PAEVETOTON I.AUbm' VISUAL ALARMS 2.BALL STOAT .FELL IUDs SICUT-OFT VALVE 4u <br /> 4.TANK MEETS RP.pUIRH MM FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT`/WAM PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 1 SINGLE.WALLED DOUBLE-WALLED Q99.OTHER °na <br /> SYSTEM TYPE Lr I.PRMURE Lj 2GRAVITY 0 T.CONVENITONALSUCDON ❑ 1,SAFE SUCTIONM CCR 4TW6(1101 ase <br /> PRIMARY CONTAINMENT I.STEELa.-CH BERGLASS [18.FLE UBLE I0.RIGID PLASTIC 664 <br /> Q 90.NONE [195.UNKNOWN 0 99.OTH®USwi(y): 1614 <br /> SECONDARY CONTAINMENT I.STENL 9T.FiDexamm Q &FLEXIBLE IO.IUOIDPIASTIC rem <br /> E3 9a.Nom .S.UNKNOWN 0 99.OT"Fit <br /> PIPINGTIIBBINE CONTAINMENT SUMP TYPE: I.SMOLEWAIL W 2.DOUBCR WALL ' W.NONE ✓we <br /> 'VLVEN1C,VAPORRECO (VR).ANDRISER/MLLPTPEYIPINGCQNSTRUCnON. <br /> VtNT PRIMARY CONTAINMENTLSTE .'mcE T.A45 u 1a.RIGIDPLASDC 0 9 NONE 099. (5/esN) <br /> VWrSW0NDARY0DNTAINMI1NT 0 L STEEL 0 4. 19. IO PLASTIC NuNa99.ms@R(samyl ,"w <br /> uMn' <br /> VR 111.104N2Y CONTAINN1GNr U T_STELL .PW�iS 0 la nlem Pl,.4gTIC 0 9D.NONE 0T9.aDeFs(Specter) �• <br /> a.-. <br /> vR RKCOry111HY CONTnINMENT LJ I,STFPL 4_F'IOfiRCLA45 U 10.RIOm PLASTIC Ut NONE Q 99,OTHER(5peelpo aseN <br /> WI <br /> VEIN TILTING tkANSIEIDN SUMPTYPE 11 1 'WALL 2C%NRVP WALL. .NON,' +ea. <br /> RISERIRNCARY CONTAR(MENT .STEEL. CFMIEROIASS 10.IUGQI PLASTIC 9d NON E3 99.OIHEA(Sppci(P) <br /> 16a't <br /> RISER SECONDARY CONTAINMENT EI I.STEEL 4.FIBERGLASS M IGIDPL.ISTIC NONE W.OTHER(Spo i&) 461k <br /> A k, <br /> FILL COMPONENTS INSTALLED ,SPIU.9UCKFT a,,rMiKERnATEIEarToMFRaTEcmR 4.CDNTAINMENTSUMP 451Ne <br /> VIL UDfDER'DISPEIVSER'C0NrA1NMENC.(UDCy <br /> CONSTRUCTION TYPE EYI SINGLE.WALL ❑2.DOUBLE WALL 0 3_NOO6PENSFRS ❑ 90.NONE 46'6 <br /> CONSTRUCTTON MATERIAL I.SREEL 0 ', <br /> FTBP.ROI N LJ I0.RIGID PULNTIC W.MINER(. d6YNe <br /> VUL CORROSIONPROTECnON <br /> STEELMMPONP.NTPRDTE TION 0 2SA0RIF(CIALANODE(S) 0 a,IMPRESSED L'URIfEN' 0 S.ISOLATION aeN. <br /> DL APPLICANT SIGNATUM <br /> 'KRTIiFCATlO1V: l wnlrP we 1LN DNl'q+aP�I•a•Y•Wb w116 He Vwdw...4vww ewawd wr wR IV bh.rlR.M�"add Vwl.1.1rr..w..aaV <br /> ead IR fW rRaRn. <br /> APPLICANT SICNATUI7 OL <br /> DATE <br /> APPLICANT NAME(prbu) ) °H' I APPLICANTTYR.F. <br /> i' tiOF N yyisd/ Ouir/r:""� <br /> UPCF UST-13-0 Rev.(Ivm) <br />