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Nov 23 09 09: 55a RAVIN# SINGH 209 47656 p. 4 UNIFIED PROGRAM CONSOLIDATED FORM /`� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(oncr"VaUM TYPE OF ACTION (Check me item only. Por RD UST pmnlllrn[cRLavt rff tlmlmd. wb'Wu 1mA Sections 1.U.I0.IV,and IX below) 4N I' I NEW PERMIT ❑ 3.RENEWAL PERMIF �'5.C$IANGE OF INFORMA77ON El G.TEMPORARY UST CLOSURE El 7.UST PERMANENC CLOSURE ON SITE 8.UST REMOVAL DATE USTPERMANENTLY CLOSED: 07a DATE EXISTING USF DISCOVERED: Op6 L FACRLTIY INFORMATION FACB.ITY lU R(AgeAcy Ulf ONY) - BUSINESS NAME(9mm�m FACILE NAME m DBA-DoingDuwi=w As) I BUSINESS SITE ADDRESS CITY Iw U.TANIK IDESCREMON TANK LUN au 'YANK MANUFACTURER TA_NIyCONPN1UrAnpN: TIPS TANKIS " A STAND-AI TANK q z oNE m A C06RARTMOMED uNrr. /�LrasTE� uR r1. DATE r4-r SYSTEM INSTALLED 435 •TANK CAPACITY IN GALLONS W NUMU; OF COMPAR TMENTS EN THE UNIT• 437 'i75 RRL TANK USE AND CONTENTS TANKUSE IaMOTORVEIICLE PUEERG U1b MMAYNA FUELM (] ILAVIATIONFUELM 4)9 ❑ 3.C14lNLCALPR0DUCT5WXk0E Cl 4.HAZARDOUSWABr 0-0-"U11 Ok ❑ S.EMERGENCY OENERATOR FUEL[L3E092516L5(gl ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN C] "'OTHER 3 43% CONTENTS PETROLEUM: 13 Iz REGULAR UNLEADED Q Ic MIDGRADEUNLEADED ❑ 1b.PREmiumuNLEADED •� 13 3,DmsEL Cl 5.JET FUEL ❑&AVIATION OAS S.PETROLEUM ELEND FUEL Q 9.OTNFR FhTROLEUm (Spenift NON-ft-TK DfUM:C] 7.USED OI, IQ ETHANOL I1.OTHER NON-PETROIJIUM S 4'� . ;TV- TANK CONSTRUCTION TYI'Ii OFTANK SmC1LF.WAIN, 2DOUEII WAIL. 95.UNKNOWN 413 PRIMARY CONTAmMEFfT L50'.RL J�PDIEROLA99 6.INCt]tNAL BLAD0E0. 441 ❑i.riVEL+Rfrm1NAL LINING 93.UN1O40WN vi.OTNRR 1." 111. SECONDARY CONTANMPNT L5TR6L iFmLD90LASS 4.FFTERIOR MPJ(0.RANE LINER .JACKETED k ❑ 90.NONE ❑95.UNKNOWN W.O'T1ff:R 41S' DYEQFDL PREVENDON I.AUIMpLE&VLSUAL ALARMS 2BAU..FIAAT FILL TIIBfi SHIfT-0FF VALV$ a3i Q 4.TANK MP.FCTS ElPA1FNIS POR EXE611'TION PROMOV[RPE.L PREVL+MIONE UIFMFM .. , ,_ � V. PROR/tl /.WAS'1'EPIPINGCONSCRIICTION _ .. . PIPING CONETRUCTIDN I.SmOLE•WALIFD DOUBLE'WALLED 99.OTEfQt SYSTEM TYPE I.IRCSSURE Z GIUVRY I.CONVENTIONAL SUCTR)N 4.SAFESVCITON IMCat WafaXill 4% flGMARY CONFAMhffiNT I.STEEL 4.FIBEROIASS &FTE7GBI.E 18.RIGID MASTIC 0 90.NONE (3 9 .UNKNOWN ❑99. m S SECONDARY CONTAINMENT 1_STEEL 6r4.FMERGLAS.S ❑ S.FLEKIWX (] m RLGm PL.ASDC 461° ❑ ".NONE ❑ .UNKNOWN ( ): PIPINC✓NRRINP.CONTAINMENT SUMP TYp6 I,SLNGIE WALL OzWl1BLE WALL W.NONE VI:VEPPT;VAPOR RECO -(m AND RISER/FD.L POE PIPING CONSTRU4MON VPNT PRIMARY CONTADOM I.STEPL 4.F�FRGLA&S 1..w Ff 11C 0 9R NONE 0 9➢.OT (S,-40 °d•' _ 6x1 vkMYSF_CONDARYCONTAINMENT 1. m 4,FmERGIA4S IU.RLOIUPLASTIC .NONE 99.OTHHL(SP fP) +wf 4n.n VR P0.IMARY GONCAINM6NT I.STRRL FiamGLASS Ej i0.N3C•m P� U 90-NONE E399.4TOIER0Pecfr) �A VR SECONDARY CONTAINMENT 0 I.STEEL U 4.FIDERGLASS 0to.RIOm PLASTIC NONE U9J.OTHER(sped&) 444' tlY1 VENT PIPWGT1tAPl1fC1 SUMP'1'YPLS ISLNGLE WAIL LDOtIa[>=WA[3. .NONE '14t'' PMER PREAARY CONTA NMNT .5T'ELl. 4.FmEROL'ac 10.RI®nAST1G M NONE N9.OTHER(Spairy) 4N I RLSP.R SECONDARY CONTAINMENT U !'STEEL U 4.FI14ERGLASS 10JUGID PLASTIC NONE 0 99.OTHER(SF ib) 4ue M11t TLILCOMPONENTS[NSTALIAD 1.9PHL tl1JCKET ..STRncPx WATWBUMM PROTECTOR 4,CONTADDAENTSUMP uDe VII:UNDER DISPENSER CONTADIMENT. CONSTRUCTION TYLE EV1.SINGLE WALL 0 2.DOUBLE WALL 0 3.NO MSPENSERS ❑ 90.NONE /e'h CONSTRUCTION MATERIAL Pl.MFL Q4.FIBERGLASS 1U.RIGID PIAS}lC 99,17DIER( auw< VM,CORROSION PROTECTION STEEL COMPONENT PROTECTION 03,SACRIFICIALANOOE(S) ❑4.HAMMED CURRENT 06.LSOLATION a9. IX. APPLICANT SIGNATURE CERTIFICATION: 1 mtl(Y D t u UST NYAIer Is tbmt W/m"^ .P1a Iwee1A k 41 ACC..m RRA In Tins a w 6 6.ab. APPLLCANT SIONATU DATE ! V,�- A�, nI'AME(print APPLICANT TITLE APPLTCAM Ni �v�✓�� Rev.(12RLI0'n UPCF UST-B-US