Laserfiche WebLink
JAN -29-2013 13:18 From:2O92347295Pa :8/14 <br />UNIFIED PROGRAM CONSOLIDATED FORM ? 3 <br />UNDERGROUND STORAGE TANK J <br />OPERATING PERMIT APPLICATION- TANK INFORMA form per UST) <br />ACTPE (Check Oce item only. Fw RM TI, UL IV,mad IX below) ado <br />qPM w rcmovat, complele only this <br />17IENE MIT 3 RENEWAL IT ❑ �CHANGEPm <br />ON <br />G TEMPORARY ST CLOSURE 7. UST F RMANENTLZOSU ON SRE 8. UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: 4 DATE EXISTING UST DISCOVERED: <br />L `FACIXATY INFORMATION <br />FACILITY ID S (Mgmey Urn Only) <br />1 <br />BUSBVB` NA {Same FACII.i NPME M DRA•Do' BusindS.U) <br />V' <br />BUS S SITE AD KESS 1 <br />CV <br />\ N <br />II:,T ),)ESCRIPTION, <br />TANK 11) <br />TANKMAN(MACIURER °53 <br />TANRCONnOURATHw: THIS TANK Is 4m <br />1 iSO��Oln�1 <br />ll�J1'� <br />I. A STAND-AT.ONE TANK <br />z.ONS iNAt�ARxMRN2EB tD8P. <br />al <br />` <br />DATE UST SYSTEM INSTALLED m <br />TANY CAP ILYIN UALWNS •� <br />NtJMt1hKUtCOMP INTBEUPIIT m <br />\ \� <br />I'O <br />YII_1ANK USE�AND CUNTENTS <br />'IO <br />TANK USE MOTOR VEHICLE FUELING ❑ 1b. MARINA FUELING Q Ja AWATIONPUELING <br />I CHEMICAL PRODUCT STORAGE ❑ 4. KUARDOUS WASTE(4mtlpUso 0a Q S EMERGENCY GENERATOR FUEL Cast: p=1.S(s)1 <br />Q 6.0173ERPL GENERATOR FUEL ❑ 95. tJNICNOWN 99, OTNER (Spm*); 4790 <br />CONTENTS PETROLEUM: ❑ IA REGllLAR UNLEADED ❑ N. MIDGRADEUNLEADED 1b. PREMIUM UNLEADED <br />❑ 3.0IESEL ❑ S.IETFUEL 6. AVIATION GAS <br />Q S. PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM N9a <br />NON.PETROLEUM: ❑ 7. USE➢OIL ❑ 10. E77f o <br />❑ I L OTHERNON-PETROLEUM J: 4Nb <br />•. ,n, IG...TAIVIGIEUNSTRUCIION . <br />TYPE OP TANK I.SINGL.6WALL. 2.DOUBLEWALL 9S. UNKNOWN 463 <br />PRIMARYCONTAINMP.NI' LSTEEL 3. FIBERGLASS ❑ 6. INFERNAL BLADDER hF. rnn <br />EL <br />7. STE+DFPERN' LINMG Q 95. UNKNOWN �, 99.OTHER (Specify): r-, Y Z <br />SECANDARYCONAWMENi [] I. STEEL FIBERGLASS ❑ 6.EATERIORMEMBRANEUNER ❑ 7. JACKETED . 4d <br />1. <br />❑ 9o. NONE 95, UNKNOWN99.OIIlER 13 SO LM45s <br />OVERFILL PREVENTION 1-AUD LE d VISUAL ALARMS 2BALL PIOAT 3. PILL TUBE W-QFF ALVE 432 <br />❑ s.TANKMEsn REouzRpmzNTs FOR E�N FROM OVERFD,LPREVENTIONE MINT <br />Y:,RROIiUCr,t<wifr5'I'EPDNPiGI�ON5�'RUG1'ION ' <br />PIPING CONSTRUCTION L SING -WALLED 2. DOUBLE -WALLED ❑ 99, OTHER 460 <br />SYSTEMTYPE AL 1. PRESSURE ❑ .GRAVITY ❑ 1.CONVENT(ONALSUCTION 4, SAFE SUCFION 23CCR 263 0 458 <br />PRIMARY CONTAINMENT Q I. STEEL 4. I MERGLASS ❑ S. FLEXIBLE Q 10, RIGID PLASTIC <br />❑ 90. NONE 95. UNKNOWN Q 99.OTHER(Seeci : 464 <br />SECONDARY CONTAINMENT' I. STEEL 4, FIBERGLASS Qe. FLEXIBLE ❑10. RIGID PIASriC <br />❑ 90. NONE 95.IJNPaiDWN ❑ 99.OUDtR(SpPci[yj: 1610 <br />P[PNO/TURB(NE CONTAINMENT SUMP TYPE I.SMGLE WALL 20ODBLE WALL 90. NONE d6w <br />VI:YEN.X VAPOBItECO ELY,',; )-ANA'It ERY FIE i$;PIPE.PIPINGGCf1!jSTiuCfIon';::', <br />:.a ::. <br />VENTPRIMARYCONTAWm LSTEEL 4.FIBEROLASS U 10. RIGID PLASTIC LI90. NONE <br />U W. OTtEiR CIP.01y) <br />d6d <br />VENT SECONDARY CONTAINMENT ❑ 1. STEEL 4, FIBERGLASS Lj 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (5pmify) � <br />VRPR24ARYCONFAINMEN7 I.STEEL K 4, FIBERGLASS 0 10. RIGID PLASTIC u 90. NONE Q 99.OINE0. (Spxiy) 4649 <br />VR SECONDARY CONTAINMENT I. STEEL 4. FIBERGLASS ❑ MIUGIDPLASTIC 0 90, NONE tj 99.OITfER (Specify) 461h <br />/MRI <br />VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 0 2. DOUBLE WALL 90. NONfi 4441 <br />RISER PRIMARY CONTAINMENT JWN 1.57EEL U 4. FIBERGLASS Lj mRIGID PLASTIC SU 90. NONfi LI 99.OTHER (Spaify) 464J <br />16'1 <br />RiSER3ECONOARY CONTAINMENT I. STEEL 0 4. FIBERGLASS LI 10. RLGm PLASTIC Ej 90, NONE Q 99. OTHER (spaib) 4wa <br />FAL COMPONENTS DST'ALUD, I. SPILL BUCKET 3,STRIKERFLATEMOITOMPROTELTOR 4.CONTAMMENT'SUMP .51. <br />VI[ UNDER"DISPENSERCON7a riT,i . <br />CONSTRUCTION TYPE 1. SMOLE WALL Q 2 DOUBLE WALL ILJ 3. NO DISPENSERS90. NONE 4690 <br />NSTR CTION MATERIAL LSTEEL Q 4, FIBERGLASS Q 10. RIGIDPLASTU p99.ODR mS 469trc <br />VM., CORROSIONPROTECTION <br />4. PRESSED CURRENT 6. ISOLATION ad& <br />STEELCOMPONENTPROTECDON ❑ 2. SACRIFICIAL ANODE(9 [1[.[ <br />JX APPLICANT SIGNA'T'URE <br />CERTIFICATION: I certify that this UST system B mmgMWe with the hazilrdow substance stored sad that the Ioformafta provided herNn is tcac, acvumle, <br />and ce with lees] r Wtemm <br />PLICANT <br />DATE 1 -T�-T 4 <br />APPLIC (pyla <br />411,4a <br />TITLE aR <br />UPCF UST -B. J/2 <br />