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JAN -29-2013 13:17 From:P092347295Paae:6�14 <br />00m a7 <br />UNIFIED PROGRAM CONSOLIDATED FORM ©� v P <br />UNDERGROUND STORAGE TANK <br />r <br />OPERATING PERMIT• APPLICATION -TANK INFORMATION (Dna mm 3 �3 <br />TYPE. OF ACTION (Check ane itcat ool,Y, FUST pmnmkot closure or removal, cooglate m1y this sermon ad Soni ms 1,14 [II, N, and U( below) 490 <br />❑ 1. NEW PERMIT 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATION <br />6. TEMPORARY UST CLOS 1. UST PERMANENT CLOSU ON SITE S, UST REMOVAL <br />DATE VST PERMANENTLY CLOSED: DATE EMSTNG UST DISCOVERED. 41N <br />I. FACR.II'YIlYF(iRMATION <br />FACE.rN ID k (AStacy Use 0*) <br />_ <br />1 <br />BL)sIWESS (S-90FAC <br />'Typos <br />BUS S SITE At C(Ty IN <br />e7 � <br />IL TANKa�FSCRIP?IO <br />ID 0 433 <br />TANK MAMLTFACMUR 4L3 <br />TANK CONDOUBATION. T1115 TANK IS 434 <br />�} <br />ii. <br />i. 0116 INANA COAG TTMENTEO itNl'f. <br />NUMBEROFCOMPARTMENTSN7HE UNlT 417- <br />DATE UST SYSTEM INSTALLED 439 <br />TANK CAPAC E <br />01, TAn M.Aft CONTENT$ <br />TANK U Ie. MOTOR VEIBLTE FUEUNQ ❑ Lb. MARINA FUELING ❑ Iq AViAT70NFU5LRIG + <br />3,CHEMICALFRODULTSTORAGE ❑ 4. HAZARDOUS WASTE WgaNlf>d Wi 05,EMERGENCYGBNSRATORPUE (Mimnis(:)1 <br />0 6. OTHER GENERATOR FUEL a 91. UNKNOWN 0 99.033168 ass+ <br />NIENTS PETROc6UM: ❑ Ie. REGULAR UN1E,ADED 13 Ic MmGRADEUNtEADEO ❑ Ih PREMIUMUNLEADEO 419 <br />➢.o¢SEL 0 s,JECFUEL 0 b.AVUTIONGAs <br />[gj B. PETROLEUM BLENDFUEL9.OTHER PETROLEUM a4w <br />NON4'ETROLEUM:❑ 7. USED IL ❑ 10. ETHANOL <br />11 IL OTHER NON-PEEROLEUM eme <br />' IV. !TA .CQNBTRU(;TION ..- <br />TYP OPT LSINGLEWALL .DOUBLEW 93 -UNKNOWN 443 <br />PRIMARY COMA (STEEL M J. PMERGLASS Ll 6. llfrmmAI. eLADD 4u <br />7.97554+NCERNAL 4MIONG uNK= 99. OTHER W 2 Our <br />SECONDARYCONTAINMENT Q I.ST911. 03. FIBERGLASSiEXTERIORM L lA us <br />90. NONE 95. UNKNOWN 99.0 S ): ( 449. <br />O RF PRBVENT1pN .A(lb®LE k VIS UAL ALARM$ Q2.1W 19[,DAT 0 3.1" TUBE -OFF VALVE <br />0. TANX MEETS RE UIRF.NEMa FOR EXEMFRON FROM OVERFOL PREVENNON OQUIPMENT <br />. ,V. -PRODUCT / ftbPI'E PIPD4G (CONSTRUCTION <br />PIPING CONSTRUCTION I. SINGLE•WALL6D2.00 1399, OTHER 40 <br />LE-WALLED3. <br />SYSTBM TYPE A. PRESSURE ❑ RA CONVENBONAL SUCTION 4. SUCTION COR .X31 4W <br />PRAIARY CONTANT9EHT' L S 4. FOERGLASs S. FIEXIBL6 MAJOR) W PLASTIC 46N <br />_ <br />090. NONE 95. UNKNOWN 099. SoNifl* 46U <br />SECONDARY CONTAMMUT 1. STHFL4. PIBEROLASS L FLEXIBLE r310. RIGID PLASTIC <br />1390,NONE 95. UNKNOWN 1399.OTHER( ): 4644 <br />PIPMC/NRBME CONTAINMENT SUMP TYPE I.SMGLEW 2. WALL NONE <br />�•. VLVENT;VCRRjAL�iARL4�ER1'16T:1'IPE.P>pINC�CQNSTRUCTION <br />VENTP MAMs4;NC ,STEEL d. FIBIROLASS 10. NGm PLASTIC u W. NONE u 99.O7NER(Splc4fy) 164 <br />VENT SECONDARY COHTAINI4ENT .STEEL J.4. FB3EROLASS in 10. RIGRJ PLASTIC E3 90, NONE 0 ".OTHER (Speeiy) 4616 <br />44IL <br />VRPRR,IARY CONCAINH6M .STEEL d.F IAS$ 10. Bf mPLA$T(C 90. NONE 99. OTHER (SpxifF) 4649 <br />VRSEC%7NOAR CO AP7AfSNT O 1. STEEL jK 0.PIBERGLASS Q I0.0.1Gm PLASTIC E3 90. rvONE Q99.OTNGR ($pmfp) 464A <br />46A1 <br />VENT PIPING TRANSITION SUMP TYPE ).SINGLE WALL 200(111(5 WALL P0. <br />RLSERPRIMA0.YCONTAMMSNf I, STEEL C3 4. FIBERGLASS 10. RICHE) PLASTIC 90. NONE U99.OTHER(Spmi&) 4uj <br />44 - <br />SECONDARY CONTAINMWT 1. sTEIL 4. F18ERGIAS3 lo, I(IGm P1ASnc 9R NONE El 99. OTHER (Spaity) .1 <br />FILL COMdftl <br />PONENTS015CALLED 1. SPILL BUCKET 3. StRIXER PIA PR075CT0R 4.CONCAI Sl1MP 461ec <br />VII.UNDER71ISPHH5Fdt'CON7'A>IVb[ENT. <br />CONSTRUCT1pN TYpE I. SINGLE WALL (7 2, DOABLE WALL ❑ S. NO DISPENSERS 90. NONE <br />CONSfR CCION MATERIAL I. STR51- 0 4. FmFRGLASS 0 I MIDP1ASTR: Q 99,9111ER( ) <br />.VRI. CORROSIpN•PROrEMON <br />MP014EN <br />S[RELCOCPROTECTION I]2.SACk6ICWLANODE(S) G 4.B.IPR=6DCURRENT I6. ISOLATION a43• <br />. .. .. DL APPLICANT SIGNATURE <br />CERTIFICATION: I ectfib mat Wis UST system B compatible with the haruduq stibstance cored ead that the info m4tioa provided hemip Is trot, mruntq <br />4ad to full B!W Ln legal uimm um <br />APPLICAN73[G <br />BATE � �� � ` <br />l <br />APPLICANT N471. <br />APPLICANTTRL +n. <br />A, <br />OPCF UST -B -112 <br />Bev. (1)12007) <br />