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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK `� c' j <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One farm perUST) <br /> TYPE;ACTION ('Check one item only. For STclostwe or removal,Complete only this.section and Serttona f,lf,ifl.1T✓,surd I helnw)[� 1. IT Lj 3•RENEWAL PERMIT (] S.CHANGE OF INFORMATION <br /> fi.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE C3 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 43 h <br /> I. FACILITY INFORMATION <br /> FACILITY ID 4(Agency Use Only) <br /> BUS ME{Same as Facility»Marne or DBA-Dning Bits lie As) <br /> MA6 A Ff_56r7_ <br /> BUSINESS SITE ADD 103. CITY M4 <br /> c <br /> IL TANK D SCRIPTIOlY1 <br /> TANK M It 432 TANK MANIJFAf TF)RFR 13 a TANK CONFIGURATTON:THIS TANK IS 434, <br /> ® 1.A STAND-A LONE TANK Complete one pap fat each <br /> t+.> Fiery Atgu., Q 2.ONE IN A COMPARTMENTED UNIT co r-m rn thowa t. <br /> DATE UST SYS M INSTALLED 435• TANK C ACITY IN GALLONS C6 NUMBER OF COMPARTMENTS IN THE UNIT 37. <br /> III. TANK USE AND CONTENTS <br /> TANK USE ❑ 1a.MOTOR VEHICLE FUELING 21b.MARINA FUELING ❑ la AVIATION FUELrNG 439. <br /> ❑3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include;Used Oil) ❑ S.EMERGENCY GENERATOR FUEL(HSC?I25281.5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN _ _ ❑ 99.OTHER(specify_); 439x <br /> CONTENTS PETROLEUM: ❑ 0.REGULAR UNLEADED 0 Ic.MiDGRADE I,iNLEADFD Q ib.PREMJUM UNLEADED 44n. <br /> W-3,DIESEL © 3.JET FUEL ❑ 6.AVIATION GAS <br /> © 8.PETROLEUM BLEND FUEL [] 9.OTHER PETROLEUM(Spee`sfy): 440c <br /> NON-PETROLE-UM7[377.USED OIL Lj 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(S eci ): 44nb. <br /> IV., TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SI`iGLE WALL 2,DOE WALL 95.L'NICt+OWN - 443. <br /> UBL <br /> PRIMARY CONTAINMENT Erl.STEEL Q 3.FIBERGLASS ©6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+TNTERNAL LINING ❑ 95.UNKNOWN Q 99.2THER(S - ): 444& <br /> SECONDARY CONTAINMENT 1.STEEL al.FIBERGLASS © 6.EXTERIOR MEMBRANE LINER Q 7.JACKETED 445. <br /> _ ❑ 90.NONE Q 95.UNKNOWN Q 99.OTHER{5 c1t) '45&_ <br /> OVERFILL PREVENTION [31.AUDIBLE&VISUAL ALARMS ALL FLOAT 3.FILL TUBE 5HUT-0FF VALVE 482. <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVEN MON E UtPMENT <br /> V. PRODUCT/WASTE.PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION _ I.SIS GLtEALL DOUBLE WALL_ 99.OTHER _ _ 4b0, <br /> SYSTEM TYPE L7I.PRESSURE_••�❑�2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION[23 CCR;263b(a}{3)1 458. <br /> PRIMARY CONTAINMENT 2-1,STEEL W4.FIBERGLASS Q S.FLFXfBLE Q 10.RIGID PLASTIC 464, <br /> _ Q ".NONE Q 95.UNKNOWN Q 99.OTHER(S ify}: 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS Q 8.FLEXIBLE I6,RIOID PLASTIC 464h, <br /> Q 90.NONE _ 95.UNKNOWN ❑99.OTHER{Specii'y): 464c <br /> PIPINGMJRBINE CONTAINMENT SUMP TYPE I.SINGLE WALL Q 2,DOUBLE WALL 90.NONE 4644, <br /> VI, VENT, VAPOR RECOVERY (VR) AND RISER I FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT Q'1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC Q 90.NONE [199.OTHER(Specify): 4 <br /> VENT SECONDARY CONTAINMENT Q'I.STEEL ❑ 4 FIBERGLASS Q 10.RIGID PLASTIC ❑ 90.NONE Q 99.OTHER(Specify): 464fl. <br /> VR PRIMARY CONTAINMENT Q'I.STEEL ❑4.FIBERGLASS 1310.RIGID PLASTIC Q 90.NONE Q 99.OTHER(Specify): 464& <br /> VR SECONDARY CONTAINMENT Grt.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE Q 99.OTHER(Specify): 4%. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ t.SINGLE WALL 0 2.DOUBLE WALL It 90.NONE <br /> RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS Q 10.RIGID,PLASTIC Q ):90.NONE Q 99.OTHER(SPwiF 464: <br /> RISER SECONDARY CONTAINMENT (3 1.STEEL d 4.FIBERGLASS ® I O.RIGID PLASTIC 90.NONE ( ".OTHER(Specify): 46411. <br /> FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAWMENT SU'41P 4512-1 <br /> VII. UNDER DISPENSER CONTAPiMENT('UDC; <br /> CONSTRUCTION TYPE _ I.SiNG_LF WALL _ Q 2.DOUBLE WALL _3_NO DISPENSERS _ 90.NOME 469& <br /> CONSTRUCTION MATERIAL '[ STEEL E3_-4..FIBERGLASS Q 10,RIGID PLASTIC (]99,OTHER(Specify) 4�b <br /> G <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION _.SACRTICIAL ANODES 4.IMPRESSED CURRENT Ll 6.[SOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION-.I certify that this UST system is compatible with the hitmrdous suhstance stared and that the Information provided herein Is true, <br /> accurate avid in U1 cam liance witft al regairements. <br /> APPLICANT SIGNATURE DATE _ 0 <br /> APPLICANT NAME(print} <br /> 4 I' APPLICANT TITLE 4n. <br /> UPCF UST-8 Rev.(IM007)-1l2 www.unldoeit.org <br />