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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> ' OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> a;n <br /> TYPE OF ACTION (Check one it&n mdy. For a ST cloture or removal.complete Sulu tMs.cec:inn and Secelarrs/,I/.111.IV,and IX below) <br /> ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 1 <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL +19n <br /> DATE L'ST PERMANENTLY CLOSED: 4t6' DATF EXISTING UST DISCOVERED. <br /> I. FACILITY INFORMATION <br /> Pc - C V <br /> FACILITY(D g(Agnrgr Use Only) - <br /> BUST, ME(Same as FanJlr}'Name nr DRA-Da;rg Busine As) <br /> Ar' esa�T <br /> . iM. <br /> BUST FSS %- <br /> ADD m1cm <br /> II. TANK D SCRIPTION <br /> 43+. TANKMAM)FACTIIRFR 433. TANK CONFIGURATION:THIS TANK IS au. <br /> TANK IDS Q I.A STAND-ALONE TANK 0o 1-eempwwaach <br /> Tq 2.ONE NA COMPARTMENTEDUNIT mtin Newit <br /> 435, TANK C AC1TY OV GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNi l 437. <br /> DATE UST SYS M INSTALLED <br /> i • <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ 3.CHEMICAL <br /> PRODUHICLE CT TOR 4.HAZARDOUSRNA AS ❑ <br /> i n AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS HASTE(IndWa ttaee Dill ❑ S.EMERGENCY GENERATOR FUEL IItSC 4251913(c439)] <br /> 1`1 <br /> 1`16.OTHER GENERATOR FUEL Q 95.UNKNOWN _ 13 99.OTHER(Specify): <br /> CONTENTS PETROLEUM: ❑ REGULARUNLEADFD Q Ic.MIDGRADEINLEADF,D ❑ Ib.PREMIUM UNLEADED 440. <br /> 93.DIESEL Q S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM(Specify): 4:4)a___ <br /> NON-PETROLEUM:ff7.i}SED OIL 10.ETHANOL <br /> ❑ 11,OTHER NON-PETROLEUM S eci ): <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 11 I.SINGLE WALL 07DOUBLE WALL 95.UNKNOWN <br /> PRIMARYCONTAINMENT e51 r.STEEL Q3.FIBERGLASS Q 6.INTERNALBLADDER 3°4 <br /> _ CJ C177..STEELINTERNAL LINING ❑ 95_UNKNOV.N 0 99.OTHER(Speeify): <br /> SECONDARY CONT_AIN_NT MEI TTTEEL 5TFIBERQ GLASS 6.EXTERIOR MEMBRANELINER Q'7.JACKETED 40 <br /> ❑ 90.NONE Q 95.UNKNOWN Q99.OTHERI_fy): <br /> OVERFILL PREVENTION Q 1.AUDIBLE&VISUAL ALARMS .BALLFLOAT 3.FILL TUBE SHUTOFF VALVE 4.5' <br /> 4.TANK MEETS RE LTIREMENTS FOR EXEMPTION FROM OVERFILL PREVE7.TONE UiPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPINGCONSTRUCTIONrvT�LSINGLEWALL ,DOUBLEVAU [y] 99,OTHER______, a60• <br /> SYSTEM TYPE [^TLPRESSURE ❑ '-.GRAVITY Q 1.CONVENTIONAL SUCTION Q 4.SAFE SUCTION(213 CCR 12636(aX3)1 451, <br /> PRIMARY CONTAINMENT L r-L STEEL 4.FISERCLASS ❑ R.FLEXIBLE Q 10.RIGID PLASTIC 464, <br /> Q 90.NONE ❑ 95.UNKNOWN Q 99.OTHEF JSpmify): 461a <br /> SECONDARY CONTAINMENT ❑ 1,STEEL ja 4.FIBERGLASS Q�8.FLEXIBLE Q 10.RIGID PLASTIC 464h. <br /> Q�9,, NONE 'E3 95.UNKNOWN Q 99.OTHER(Specify) 464c <br /> PIPINGlfURBINE CONTAINMENT SUMP TYPE Er I.SINGLE WALL L3 2 DOUBLE wALL 9100.NONE 4644 <br /> VI. VENT, VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING.CONSTRUC_ TION <br /> VENT PRIMARY CONTAINMENT a L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE Q 99.OTHER(Specify): qlp j <br /> VENT SECONDARY CONTAINMENT a 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE Q 99.OTHER(Specify): <br /> VR PRIMARY CONTAINMENT Gr 1.STEEL _❑ 4.FIBERGLASS Q 10,RIGID PLASTIC Q 90.NONE Q_99.OTHER(Specify): <br /> VR SECONDARY CONTAINMENT arl.STEEL ❑ 4.FIBERGLASS Q 10.RIGID PLASTIC Q90.NONE Q 99.OTHER(Spedry): 46aM1' <br /> VENT PIPING TRANSITION SUMP TYPE _ Q 1.SINGLE WALL Q 2,DOUBLE WALL 90.NONE <br /> RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS Q 10.RIGID PLASTIC ❑ 90..V'OFE Q 99.OTHER(Specify): i60)) <br /> 464't. <br /> RISER SECONDARY CONTAINMENT Q 1.STEEL Q 4.FIBERGLASS ❑ 10.RIGID PLASTIC D 90.NONE Q 99.OTHER(Speeify): 464k1. <br /> FILL COMPONENTS INSTALLED 1.SPIU 13 3.STRIKER PLATFIBOTTOM PROTECTOR 4.CONTAINMENT SUMP <br /> VII. UNDER DISPENSER CONTAIA'MENT(UDE) <br /> CONSTRUCTION TYPE .SINGLE WALL____. ❑ 2.DOUBLE WALL_ 3 1 N 90,O DISPENSERS _ NONE 469. <br /> CONSTRUCTION MATERIAL L STEEL ❑ 4.FIBERGLASS Q 10.RIGID PLASTIC Q 99.OTHER(Specify) 449, <br /> 4696. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION _.S bCRIFICIAL.ANODES 4.IMPRESSED CURRENT 0 6.ISOLATION '4e <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I cert)y th this `S v et m 3s compatible with the ha"rdom aoham.e. stored and that the Informatian pmvided hereto i. true, <br /> Accura a sec ful ca is ce with legal r aimmenta. _ <br /> APPLICANT SIGNATURE <br /> APPLICANT NAME(printJ .A _O2Ff'6/ t �CC APPLICANT TITLE nT' <br /> UPCF USTA Rev.(12/2007)-1/2 www.untdtKe.nrg <br />