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Dec 05 11 05: 21p - p. 4 .+I 1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK.INFORMATION(One fmsD per usT) TYPE OF ACTION (Check ooeitam only Foran UST permanent ctosme or removal,complete ody this section and Sectiow L IL W,N,and IX below) 930 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON STTE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 9101 DATE EXISTING UST DISCOVERED: Ooh `'. 'I::Fi1CILITYINFORIINA�IU�T, , '.,` BUSINiss NAME(Same ea FACI(L�ITY N ME�/ B)A•boing Badness As) BUsnY�ADR G 5 7 /.9 MVV 03 CITY164 v 7 II :TANKDESGRIRTYUN- TANK ID# 031 TANK MANUFACTURER 433 TANRCONFIGURATION:TIUSTANlc19 431 ®ILA STAND-ALONE TANK 37a15G7g66 )( rX�s ❑2.ONE IN A COIdPARTMENTED UNR. DATE UST SYSTEM INSTALLED 435 . TANK IN GALLONS °3 NUMBER OF COMPARTMENTS IN THE UNIT 'n i�19 b o0 2 III.TANK psE tiND CONTENTS' TANK USE 0 Ia MOTOR VEHICLEFUELING ❑ IIx MARINA FUELING ❑ Ic.AVIATIONFUFLNG OS 03.CHEMICAL PRODUCT STORAGE 04.HAZARDOUS WASTEGMpda Us OM 05.EMERGENCY GENERATOR FUEL Um 1932u-X5 )) 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER(S ): N9a CONTENTS PETROLEUM: O Ia REGULAR UNLEADED 0 Ia MIDGRADEUNLFADED El I a PREMIUM UNLEADED a40 ❑ 3.DIESEL 0 5.JET FUEL ❑6.AVIA77ON GAS 0 &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S um NON&EMOLEUM: 7.USED OIL 10.ETHANOL I1.OTIIER LEUM '� - I�=�'ANKGOlYSTRi?�T10N .pfi'rH•3�. .�.,,s s TYPEOFTANK LSING[B WALL 2.DOUBLE WALL 95.UNKNOWN a43 PRDAARY CONTAnQdENT U LsTEFI 12 3.FMERGLASS U 6.INTERNAL BLADDER a44 7.STEEL+INTERNAL LINING L' 95.UNKNOWN ❑ 99.OTHER 41N SECONDARY CONTAINMENT 0 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.IACRLTED u3 _ 90.NONE kLUNKNOWN 99.07HER 5 °43+ OVERFILLPREVSNf10N 1:AUDIBLE&VISUAL ALARMS 2.BALLFIOA7 3.FILL TIt[BE SHUT-OFF VALVE 4A 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.;PRODUCT`�t'S�`AST'E-PIPING CONSTRIIC3701�" , PIPING CONSTRUCTION I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99:OTHER s< 460 SYSTEMTYPIS 1.PRESSURE ❑2.GRAVITY ❑ 3.CONVEN7TONAL SUCTION 4.SAFE SUCTION CCR 43g PRIMARY CONTAR04ENT i.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Specify): 46a SECONDARYCONTAINKENT 0 !:STEEL E9 4.FIBERGLASS 0 LFLEMLE ❑ IO.RIGIDPLASRC 4611 090,NONE 95.UNKNOWN 099.OTHER(S ): 46k PIPINGITURBINE CON TAINMENTSUMPTYPE 1.SINGLE WALL 2.DOUBLEWALL 0 90.NONE °Nd 11` 11,MAYOR OOVEItY ,. ,),AND RI i'i.FII L.kIFE:PIPI NG COPI$TR[1CTION V NTPRIMARYCONTAINMENT 1.STEEL 4.FIBERGLASS N.RIGID PLASTIC 90.NONE' '99,07HER(Speciry) 4641 VENT SECONDARYCONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90 .NONE 99.OTHBR(SpceRy,) 461! Spa VRPRIISMYCONTA[Pa.IENT El I.STEEL 4.FMERGTASS 0 10.RIGID PLASTIC 90.NONE ,j 99.OTHER(Spedfy) 4641 464 1 VR SECONDARY COMAINNIENI' 1.STEEL 0 4.FIBERGLASS 0 !0.RIGID PLASTIC p 90.NONE f 99.OTHER(Sp¢ify) 46fi 4N6I VENTPIPING 7RAIS5ITONSUMP TYPE 1.SINGLE WAL[. Cl 2.DOUBLE WALL IT 90.NONE a64i RISER PRIMARY CONTAINMENT IX 1.STEEL U 4.FIBERGLASS Ll 10.RIOIDPLASTIC U 90.NONE L4 99-OMR(Specify) 46cj 464'1 RISERSECONDARYCONrAINMENT (.STEEL LASS 4.FIBERG _. . I0.IUGDPLAETIC 90.NONE 99.ODIER(Spxi*) - 461k 16141 FILL COaIPONEMSINS[ALLHD j&LSPlLLBLK= OFSTRIKERPLAT&BOTTOMPROTECTOR - 4.CONTAINK¢NI'SUIrfP 4IIsc ' �..�' , �- _.+:; , ,:�°IL;UNDER`DISPEI!tSER:CQLV!4'A7NMENC.fiJAC)_ ` CONSTRUCTION TYPE • ®.I.SMOLE WALL D 2,DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE CGNST tl=!N!MAIRRIAL I.STEEL. 4.FIBERGLASS EJ IO.RIGIDPLASTTC • 99.OITIR(S ) YIII- CORROSION_PROTE�TION' STEELCOMPONENTPROTECTION 0 1.2 SACRIFICIAL ANIODE(S) ❑4.IMPRESSED CURRENT 6.150LA7 14 4°a IX.'APPLICANT SIGNATURE' CERTIFICATION: I cerEfy tlu[this UST sYrte®t9 compntlble with the harardow substance emred and Ihtt the information provided herein is iron,nonerah, sod In fuE com (Lace wbh i al u{remeats APPLICANT SIGNATURE (', DATE ta�a 49a APPLICANT NAME&W) Suj<y N� f/),f aI. APPLICANTTIIS:E1 a�y1rJ'�M 4Tt UPCFUST-B-L2 J c/P W/ MB Rev.(1L2om