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O1-21•li <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One fo5m per UST) <br /> TYPE OF ACTION (Check o9ue item only. For a UST closure or removal,complete only ihisseciion and Sections 1,11,II{IF,andLYbelow) 490. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 43a. DATE EXISTING UST DISCOVERED: 430b. <br /> FACILITY ID 4(Agency Use Only) <br /> BUSINESS NAME(Smite as Facility Nome or DBA-Doing Business As) 3. <br /> �e�' a le fern IND <br /> BUSINESS SITE ADDRESS i� Im. CITI <br /> 1 D �.-.c.T�.�o I l� Y I �N✓'r0 Ia- i <br /> - 1'4NIK II.Dr 112 TANK MAN UFACTURER 433. TANKCONFIGURATION:THS TANK IS 494. <br /> { �Tr J 3 G o M I.A STAND-ALONE TANK Compleleeea pesefor eah <br /> 2.ONEINA COMPARTMENTEDUNIT wmpammemmtwuno. <br /> DATE UST SYS INSTALLED 435. TANK CAPACITY IN GALLONS 496. NUMBER OF COMPARTMENTS IN THE UNIT 495. <br /> 7 � I tz000 <br /> TANK USE 1L is.MOTOR VEHICLE FUELING ❑ 16.MARINA FUELING <br /> ❑ 1c.AVIATION FUELING 499. <br /> ❑ 3.CEIBhBCAL PRODUCT STORAGE [34.HAZARDOUS WASTE(lecluda Hexd 00) 13S.EMERGENCY GENERATOR <br /> ATOR FUEL(HSC§2528[.5(,)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER 3 439,. <br /> 99.01BER <br /> CONTENT'S PETROLEUM: [I is.REGULAR UNLEADHiJ El1c.MIDGRADE UNLEADED �Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL. ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ._,.._.__ ❑ S.PETROLEUMBLEND FUEL, ❑ 9.OTfIBR PETROLEUM(Spec't�: HOe. <br /> NON-PETROLEUM❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ II.OTIIERNON-PETROLEUM Specify): Mae. <br /> TYPE OF TANK I.SWGLE WALL ® 2.DOUBLE WALL [3 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ®,L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 449. <br /> ❑ 7TSTEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 444, <br /> SECONDARY CONTAINMENT ❑ 1.STEEL X3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> ❑ 90.NONE 0 95.UNKNOWN ❑99.OTHER Specify): 44sa <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS M2.BALLFLOAT R 3.FILL TUBE SHUT-OFF VALVE 452, <br /> 4.TANK MEETSREGUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> PIPING CONSTRUCTION 13i-SINGLE WALL 15 2.DOUBLE WALL Q_99uOTHER 40. <br /> SYSTEM TYPE ®,1.PRESSURE___ ❑_ _❑2.GRAVffY 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 129 CCR g7636(eX3)) 453. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 9 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTTC 464. <br /> _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL R1 4.FIBERGLASS ❑ &FLEXIBLE Q 10.RIGID PLASTIC 464b. <br /> D 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): ae4c. - <br /> MPING/'I I1RElNE CONTAINMENT SUIvlPTYPEIL I-SINGLE WALL 02.DOUBLE WALL 090.NONE 4644 <br /> mum <br /> V]NI PRIMARY CON FAINMEN I (g.I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC Q 90.NONE ❑ 99.OTHER(Specify): 464,1: <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLAS77C Q 90.NONE ❑ 99.OTHER(Specify): 4MD <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL M.4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTTER(Specify): T64g <br /> 4§49f <br /> VR SECONDARY CONTAINMENT Q 1.STEEL.. ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify); 469h <br /> 464h1. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL [.i 9D.NONE 464 <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL 10 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 9D.NONE 099,OTHER(Specify): -- 4M <br /> _ 964'1. <br /> RISER SECONDARY CONTAINMENT C11 STEEL [14.FIFIBERGLASS ❑ 10.RIGID <br /> -____PLASTTC ❑ 9D.NONE E3 99.OTTiER(Specify): 4444MI. <br /> F[LL COMPCINCNIS INS'FALLLp -. . _..._......________-______, <br /> 14FJ BUCKET 193.STRIKERPL-TEMOTTOMPROTECTOR ❑ 4 CONTAINML\ SUMP d`Tea. <br /> In <br /> 7�TFEL. <br /> CFIU YPF I NN WA'J, ❑ 2-DOU13LE WALL <br /> ...._......_. _-0 3.NODISPENSERs El 10 Noir 46sr� <br /> CTION M1 TFRIAL Ilt I M t FL ❑ I FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTTIBR(Specify) '�°b <br /> flow <br /> IPONI NI FROILCtION <br /> - - C-1 SACRIHCIALANOD 3 ❑ a.[MP2ESSID CURRENT Q 6.ISOLATION - <br /> 448. <br /> CERTIFICATION: I certify that this UST'system is compatible with the hazardous substance stored and that the§nfarmetlon providedherein is true, <br /> accurate,andln full complignce with legal requirements. <br /> APPLICANT SIGNATUREDATE /® /.3 / 470. <br /> APPLICANT NAME(prim) 4n APPLICANT TITLE 4M <br /> / h�MA9 rroJ <br /> UPCF UST-B Rev.02/5007§-1/2 www.mahlocs.ore <br />