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12/22/2011 15:08 2094640138 trvUircurvm�v �� r,�l-� QIP UNIFIED PROGRAM CONSOLIDATED FORM I �� UNDERGROUND STORAGE TANK L/ OPERATING PERMIT APPLICATION-TANK INFORMATION(One Fom1 P., E TYPE OF ACTION (Ghent rme i/rm only. Fn mr UST Pem101NM nlMule or nxDIV01.ronplae only this sttls.ion udCIANGF OFfNF)ORI IAAU�ON M ,)o ilt L p 1.NEW PERMIT ® T.RENEWAL PERMIT E.VSTREMOVAL El b.TEMPORARY UST CLOSURE T.UST P NBNT CLOSURE ON SITE DATE VST PERMANENTL,}YI ,CLOSED: DATE EXISTING UST DISCOVERED slrw;FQiil' I`91 YFS'I'''.1'1'IF31M M1°�:'`n w N•. . .io.�u,l� I� AA.AR1I�Cv-NgllR I , FACILITY ID 0(AgMY Um EMV) "'E" :1 \ ^rI "r F BUSINESS NAME(Sime w FACILITY NAM.oDHA-DngOsimY%A+ �s Ca /AL) at BUSINESS STFE ' CITY CArn //^/� 11 4kIYe l:('{I"1}d, r W Y1e 91�H'�1'I n1Y LN,k D1iSk `IbTf' ,'v..Y' Y. y�`.nt ..\' 1 .. :..'COI/ „tl•,� ,w::; F 1�; .-' ;•::••. r+ 7 �� .,•• • ul TnNKmNF'LOVRATIDN TWSTANKIS SA /��O. TANK W M TANK MA ACIURER �iN\JCA UN yyy ❑l ASTANA ALONE MVI -/ 6 `I ` 7�1 �ONB IN A CGMCARTMENTFD low. .. J EOF EM y `[rRVIC DATEUSTSYSTEM MS 51 TANK CAP IN G LLONS 'ls NUMBERO['JPARTMEN73 INTHSUNTC J. �IAfdK VSE AND:I'.V .n.Ya�� .Y IIu Y e. 4 TA. USE s.moTORVEIDCLEFurELn40 ❑ IO.MARINAFUELING k.AVIATION FV9.NG •.. 0 3.CHEMICAL PRODUCT STORAGE ❑ 1.HAZARDOUS WASTE MKIrJe.Vw1 N) 0 5 EmMGWCY GENEIATURRIELPEC SIM)WA filer ❑ 6.13TBERGENERATORFUEL I97.UNKNOWN 099.OTHER IS CONTEN)3 PETROLEUM: ❑ It REGULARUNLEADED d Ic.MIDGAADE IIM.EADm (�]-NKPRLl1IUM I1NI.EAD� 0 3.DESEL 0 S.TFT FUEL 0 6.AVIATION GAS as 13 0.PETROLEUM BLEND FUD. ❑ 9.OTHER PETROLEUM S NON-PETROLEUM'0 T.USm vw 10.ETFIANOL tl OTTER MDN4mxzUM /�w�� y' / _.. h 1!' T } j Y •F rl'it�I F N M:RA�A�. 2 4,1 'rla.:::�t IV TA1Vl",b,1V M !' TYPE OF TANK 1, LE WALL DOUBLEaN.L ❑ 95.lINRSIOWN All PRIMARY CONTAINMENT .ST a% 3.F]BERGLASS ❑ 6.INTFANAL HLAODER 111 ❑ 9.S7EFI.♦/NSERNAL LINING ❑ 95.UNRNOWN 99.OT¢R 3 yl SECONDARY CONTAINMENT 1.STEEL QS^T)BEROLAS3 0 6.LTCTERIOR MEA0RA19E LINER ❑ T.IACKJ?LED .1. ❑ 90.NONE 0 9S.UNKNOWN ❑ .OTHER 9 n Is1. OVERFILL PREVENTION Ll 1.AUDIBLE B VISUAL ALARMS 0 T BAIL FLOAT FILL TUBE SHUT-0FF VALVE a TANK MEETS REOVI0.E6MNn FOR EXEMPTION FROM OVERFILL PRE•VRN ION �I t ,�`•':?(,III 1�i� ?i,'+!T,! ,'2Pi i�"31p 1 V:\PR(�/IUCT,K�W�S`.'T6 fIE11!�,✓C'.CONS'LR,Y)C'17 .... _. .- 1� TRvrno+ 1 s LE.wnu m L�wAum 99.orxl� .PRESSURE ❑ AAVRY 3.CONYENTIONAL SUCTION I,SAFE SUCTION CT:R O c 'ss S TYPE ID.RIORT PLISTIC Is1 PRt YCONTAINMENT ❑ 1.STEPJ. 1.PIBE0.0LA35 ❑ R.FLF]®U Isl„ ❑ W.NONE ❑ 95.UNKNOWN ❑ 99.ODIER(S Ic1e SECONDARY CONFANMENT 0 i.STEB. Lm f IBEROLASS 0 0.FFEKIBLE 10.RIGID PERSTE .s4 O 90.NONE UNKNOWN 0 99 OTHER 'b)• .Ma W CONI SUhP TYPE 9W 0 2.DOUBLE WALL 0 9o.NONE .. c.`'° VA ?'�, "Apo,'RE '�sltY �;UVD$ISEkfFII.L�lIPE�PIPiIyG EONStRUCTION '.Fr VFT7 PRIMARY CDNTAINMEM 9TEP.L O 1.FIB RS 10.A1G1O PLA 9D NONE 99 GrnETt(Spa+p•) .Illi WWSECONDARYCONTANMENT ❑ 1 STEEL I,FIBEROLA39 10.AI®PLASTIC ❑ 990THFR(SPa�CYI It.! .Mn VR PRIMARY CONTAl NT ' I.STHP,L 1.FIBERGLASS (/.RIGID FLA9I ❑ 90.NONE 99.UTHEJR(spwify) ley IM 1 VR SECONDARY CONTAH9MENT ❑ (.STEEL 1.F)BFROLASS 010.RWm PLASTIC GNP. 099 OTHER(SOR'61 IMh MPI PIPNGTRANSRIUN SUMP TYPE 1.SINGLE WALL. ❑ : DOUBLE WALL NON 1"1' R ER PRIMARY COOMN ❑ I.STEEL ❑ 1_f]BERGI.ASS ❑ 10.RNiW PLASTIC 90.NONE 99.OXNER01-l)r) ly .M 1 RIS ERSECUNDARYCONTANAZNT 0I.STEEL I,FLBERGLS99 ID.RIGID pLA3TC .NONE ❑ 99.OTNFA.(30ofy) 164 IWI FILL COMPONENTS INSTALLER ILL BUCKET TRIXBR PLATEMOTTON PROTECTOR ee r• p,• , I c l er ,� ��'i�� ' . r a� 1: . °.VIL.:YYNDEit IiISPEHSEA GlSN1�Ad11�1M�N2'(11tlCp � ' , 1 . :r. ...t^* L '".`�:- , •• ;A•; RUc coN3TRt)cGON TYPE I. Le wnu ❑a DOUBLE WALL 3.NO DISPESIFRt9 P 90 NINE INz ON MA1fllIALWE Frm ❑ 1 FI KE A33 w 10.KM 99.0 COPE STEEL COMPONENT PROTECTION 0 T.SACKTICIAL ANODE(S) .., .../lt y❑�•'4�{DAPRESSROCURRSM 0 6.EOIATRTN 1T9' Y.II��tIY'a( P,d�i'!>l I �i"\.i. .il':Yr�I -lI�Fi16:'vl II No v.<;;.,OTz .:. .-..•. CERT[FICA•RON. 1 aestily tFet 9RLA USE Fy10ew Ie eewpRNbb.ri1R Nle eaNeYn s.Menee NmeB M Mr 5119 ihFt•RtlM vP09YM M9eh i9 OrR AnarY4 R0A h RIB n� Oee N1 le 1 i9e1919R4• APPLICANT SIGNATURE DATE 12, LII to MPLICANT NAME(priM) APPLICANT E UPCF IRT-B-IR Rev.(I]FA00T)