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as ~'' UNIFIED PROGRAM CONSOLIDATEI0"OR.tiI UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One fom M UST) TYPE OF AC TION (Check one item only. Foran USIT Penneneat closure or removal,complee only this section and Sections 1,it,III,IV,and LY below) ❑ I.NEW PERMIT EYI.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6 TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El S.UST REMOVAL 'f DATE UST PERMANENTLY CLOSED: I DATE EXISTING UST DISCOVERED: ' I 1. FACILITY INFORMATION FACILITY(D p(Agency Use Only) BUSINESS NAME(Same m FACILITY N or DBA-Doing Business As) 3 1 BUSINESS SRF DRESS �.. 193 CRY / i s CjS Z la` _?o Ltf / v (�OoJ sz IL TANK DESCRIPTION TANK mN 431 TANK MANUFACTURER '33TANKCONFIGURATION: THISTANKIS ,S � I�e ❑ I.A STAND-ALONE TANK ed$e4I ZjV V. ONE M A C060AILTMENTED UNIT. � C farsdt vtlrc aryl. DATE UST S M ALLED OS TAN CAPACRY M . ONS C36 NUMBEOMPARTNIE Z E UNIT 437 _ i0- f a a M.TANK.USE AND CONTENTS TANK USE ❑ Is.MOTOR VEHICLE FUELING Q Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 139 ❑ 3.CHEMICAL PRODUCT STORAGE. Q C.HAZARDOUS WASTE(Mutn L OPO Q 5.EMERGENCY GENERATOR FUEL(HSC 125NI.RCH ❑ 6.OTHERGENERATOR FUEL Q 93,UNKNOWN Q 99.OTHER (Specify): 43% CONTENTS PETROLEUM: ❑j&REGULAR UNLEADED ❑ It.MLDGMDE UNLEADED ❑ Ib.PREMIUM UNLEADED "0 1 ®'3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL Q 9,OTHER PETROLEUM S ifs): NON-PETROLEUM 7.USED OIL 10.ETNA.NOL CI I(.OTHER NON-PETROLEUMS 9`W IV. .TANKCONSTRUCTION TYPEOFTANK I INGLEWALL .DOUBLE WALL 95.UNKNOWN C43 PRIMARY CONTAINMENT 1.STEEL J.FIBERGLASS 6.INTERNAL BLADDER "` Q T.STEEL•INTERNAL %,& Q 95.UNKNOWN _Q 99.OTHER (Spaify): _ u'r SECONDARY CONTAINMENT 1.STEEL (�'S.%,&ASS ❑6.EXTERIOR MEMBRANE L[NER ❑ L IAOKETED uT 90.NON8 95.UNKNOWN 99.OTHER ): us. OVERFILL PREVENTION LOUT)®LER ALARMS .BALLFI-OAT J.FILL TUBE SHUT-OFF VALVE CR. ❑ C.TANK MEETS REQUItEMENITS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT Nlaw V. PRODU /WASTE PIPING CONSTRUCTION, PIPING CONSTRUCTION I GLE-WALLED .DOUBLE-WALLED 99.OTHER l60 SYSTEM ME I.PRESSURE 2 RAVTTY 3.CONVFJYTIONAL SUCTION 0 C.SAFE SUCTION 11 CCR ".X31 CSI PRIMARY CONTAINMENT u1.STEEL A.FIBERGLASS Lj S.FLEXIBLE U 10.RJGID PLASTIC l6t Q 90.NONE ❑ OWN 11399.OTHER(S ): 's'a SECONDARY CONTAINMENT 1.STEF1, e.FIBERGLASS S.FLEXIBLE 0 ID RIGID PLASTIC C6A Q 90.NONE ❑ 9 . KNOWN ❑99.OTf6R( 'ry): ' PIPING?URBINE CONTAINMENT SUMP TYPE I.SMOI-E WALL 2.DOUBLE WALL 90.NONE '� VL VENT, RECO '(VR)Al!TDRISI�RIFILI PIPE PIPING CONSTRUCTION. VENT PRIMARY CONTAINMENT 1.STEEL. C.FTBEROLASS 10.RIGID PLASTIC !b ONE 99.OTHER(Specify) C6Cr Ca ci VENT SECONDARY CONTAINMENT I.STEIsl. 6. IBERGLASS i0.R1GID PLASTIC 90.NONE 99.OTHER(Specify) 161f _ +stn VR PRIMARY CONTAINMENT 1.STEEL e.FIBERGLASS 10.RIGID PLASTIC 0 90. E ID99.OTHER(Specify) VR SECONDARY CONTAINMENT I.STEEL Ej e.FIBERGLASS 0 10.RIGm PLASTIC 90 NEU %.OTHER(Sp dy) 161e e61e1 VENT PIPING TRANSITION SUMP TYPE LE WALL2.00UBLE WALL 90.NONE e60 RISER PRIMARY CONTAINMENT I.STEEL C.F ERGI_ASS IO.RIGIDPLASTIC 90.NONE 0 99.OTHER(Sprcify) 464i RISER SECONDARY CONTAINMENT I.STEELC.FIBERGLASS L0.RIGMPLASTIC 90.NONE 99.OTHER cify (Spe ) u'e b k) FILL COMPONENTS INSTALLED of I.SPLA BUCKET U 3.STRIKER PLATEIBO TOM PROTECTOR C.CONTAINMENT SUMP 451. UNDER DISPENSER CONTAINMENT(UDPG) CONSTRUCTION TITE CoSINGLE WALL .❑IDOUBLE.WALL U1.NO DISPENSERS Q 90.NONE '999 CONSTRUCTION MATERIAL. 1.STEEL C.FIBERGLASS 10.RIGID PLASTIC 99.OTHER( VDI. CORROSION PROTECTION j STEEL COMFONE>T PROTECTION ❑ 2.SACRIFICIALANO S) ❑ e.IMPRESSED CURRENT rgr6.ISOLATION APPLICANT SIGNATURE CERTIFIC 1 N: c fy diet tomis top tlIsla with the heterdom suhstence,stored dud that the Information provided hereim is Irue,accurate, aW in fall tem HY laffai matte. APPLIC DATE (©tf 0 APPLICANT NAME print ` `d1' APPLICANT TITLE UPCF UST-6-IR Rev.(INR00'T)