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UNIFIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE'fANK (One Toon per UST) OPERATING PERMIT APPLICATION -TANKINFORMATION b �y TYPEOFACTION !Checkmmrlerrr mrh. Fara cm,",e or,er..om.."'plebooM This see''and Sec❑n5 CH ANGE OFIallNFORMATION ❑ I NEW PERMIT (RENEWAL PERMIT S UST REMOV AL 7.UST PERMANENT CLOSURE ON SITE ❑ u9w 5.TEMPORARY UST CLOSURE +Ria DATE EXIS7MG UST DISCOVERED' DATE UST PERMANENTLY CLOSED. 1. FACIL�pIL)►IATION FACILITY IO M(Agenm Use Onh) BUSINESS NAME nn ns FOG14B:1"'arr or A-lloirrg Brrsiness'Is/ 103 CITY Z la. BUSlNE55 SIT -ADD :5� ` d Com¢. I1. TANK DESCRIPTION vl'-. K MANUFA TURER i)3. TAN ONFIGURATION:THIS TANK IS TANK IDM ASTAN6ALONETANK C"'^^e't O^`^'�1p""a //s(v � AJ • ?.ONE INA COMPARTMENTED UNIT sem_ ---- �.1 J3, ua. NUMBER �TMEN T UNIT rDATEUST YSTEM 1TALLED TANK CAPAPC G LLOiy•10 l�iiIII. TANK USE AND CONTENTS J9❑ IaAV1AilUNFUELINGUSE laMOTOR VEHICLE FUELING 0 Ib.MARINA FUELING 013.CHEMICAL PRODUCT STVRAGE ❑ 4.IIAZARDOVS WASTE IIneINn USN Oiq ❑ S.EMERGENCY GENERATOR FUEL(HSC i'-PH.51d1Qe.O'RiER GENERAT VEL � 93.UNKNOWN _ Q 99.17THER(Sped )'.ENTS PETROLEUM: 3. REGULAR UNLEADED O 5c.JET FUEL IDGRADE UNLEADED O 6.AVIATION p S FADED e.9e Q S.DIESEL 0 B.PETROLEUMBLENDFUEL Q 9 OTHER PETROLEUM(Sr fy)_-_ -- - -- YON-PET0.0LEVh):� ?.USED OIL 10.ETHANOL Q I I.OTHER NON-PETROLEUM(S i ): IV ANK CONSTRUCTION rEF DDER _ 1 GLE WALL =.DOUBLE WALL Q95.UNKNOWN _-_-_------- µ, ___ -6.-INTERNAL _-_-__. TAINMENT .STEFl 0 3,FIBERGLASS Q 95.UNKNOWN LA 0 99.OTHER(S�if 0 T.STEEL•INTERNAL G -- MSa TED ONTAMMENT O 1.STEEL .FIBERGLASS b.EX'fER10RMBRANE LINER Q T.1wCKEQ 90.NONE C3 95.UNKNOWN Q 99.OTHER(S fY)VENTION SUA OTAUDIBLE&ANK MEETS'REQUIKEM MSS FOR EXEMPTION FROM OVERFILLP2. LLFLOAT Er 3REVEN ON EBE H UIPMENT�VE `- V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION NGLE WALL- ?_DOUBLE-WALL 99.OTHER -'--'--,y-I $YSTEM TYPE LPRFSSURE2 RAVITV 3.CONVENTIONAL SUCTION Q LSAFE SUCTION •,-I CCR{xWe(SR311 ------------ l FIBERGLASS Q S.FLEXIBLE Q 10.RIGID PLASTIC PKIMARYCONTAINMENT Q I.STEEL 9e1• _ -� 90_NONE _ 95 KNOWN _ ❑ 99.OTHER(Sped ): _, w+b.I SECONDARYCONTAINMENT 0 I.STEEL FIBERGLASS 0 S.FLEXIBLE ❑ 10.RIGID PLASTIC 0 90.NONE13 95 _KNOWN 0 99.GTHER(_S�mify) PIN ? BI PIGURNE CONTAINMENT SUMP TYPE __ SINGLE WALL 2.DOUBLE WALL 90.NONE VI, VENT,VAPOR!! W)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT_PRIMARY CONTAINMENT ❑ LSTEEL 4.FIBERGLASS 0 10.RIGID PLASTIf ❑ 90-NONE ❑ 99.OTHER(Syecifyl:___W1. VENT SECONDARY CONTMENT 0 I.STEEL 0 1.PbERGLASS 0 10 RIGID PLASTIC 0 90.NONE 0 99,OTHER(Specify): eZn VR PRIMARY CONTAINMENT 0 I.STEEL LK4.FIBERGLASS 0 10.KIGID PLASTIC 0 90.NONE Q-99.OTHER(Sploty): VR SECONDARY CONT'AINME_NT 0 1.STEEL Q e.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99 OTHER(Specify) �R VENT PIPING TRA NSITl NSU_MPTYPE ❑ 1.SINGLE WALL_02.DOUBLE WALL 090. .(SER PRIMARY CONTAINMENT 1.STEEL ❑ 1 ERGLASS 0 10.RIGID PLASTIC 0 90 NONE 0 99 OTHER(SWify) _ ee� !)RISER SECONDARY CONTAINMENT 0 I. EEL Jr4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE Q 99,OTHER(Specify)'. ef4"1 FILL COMPONENTS INSTALLED _Lpq SPILL BUCKET ❑ 3.STRIKER PLATE/SOTTOM PROTECTOR Q 1.CONTAINMENT SUMP +Imo•` _ V ISPENSER CONTAINMENT(UDC) CONSTRUCT ION TYPE DOUBLE WALL ].NO DISPENSERS U90.NONE W• CONSTRUCTION MATERIAL till STEEL 01 FIBERGLASS 0 MRIGIDPUSTIC Q".OTHER(Specify '' 1 VIII. CORROSION PROTECTION .,:. ... STEEL COMPONENT PROTECTION 02.SACRIFICIAL ANODE(S) (3 1.IMPRESSED CURRENT b.ISOLATION Mt. APPLICANT SIGNATURE 1' I- CERTIFICAT , I cc fy that th U ynem Is padble with the hamrdow svW"ce sloredd 1 t the information provided' ril is Irae, mn pd 1. el (Wee [ An ulntaewts. __ _ __ APPLICANT }-- DATE T� / ,O am. � APPLICANT NAME(prim) lL/ ' - +tl' APPLICANTTI'TLE - •t? �/ UPCF'L'9T-BRev-(12/2007)•V2 www.ualdocs.wj