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UNIFIED PROGRAM CONSOLIDATED FORM L{ J 25 r i L <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST pemlanent closure or removal,complete only this section and Smiom I,It.III,IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT $(5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4101 DATE EXISTING UST DISCOVERED: 439b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Oafy) I <br /> BUSINESS NAME(Samc u FA.CILfI'Y N or PA-Doing Business As) A�O I' L.7 6> �^ 3 <br /> J -crV/ -I <br /> BUSINESSSITE ADDRESS Im <br /> / ,erY crry <br /> IL TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433 TA NKCONPIGURATION:TIISTANK IS 434 <br /> S / e bpd , ❑LASTAND-ALONETANK <br /> 2.ONE INA COMPARTMENTED UNIT. <br /> .0t COMPARTMENTED <br /> DUNIT. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACIl'Y IN GALLON 436 NUMBER OF COMPARTMENTS IN THE UNIT 4n <br /> v o. 7� <br /> M.TANK USE AND CONTENTS <br /> TANK USE KI..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING <br /> ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hitl Ueed Oil) ❑ 5.EMERGENCY GENERATOR FUEL[DISC 125281.3(c)1 <br /> Q 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% <br /> CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED _K It.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4104 <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): <br /> a4ob <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL 095.UNKNOWN 44l <br /> PRIMARY CONTAINMENT" ❑ 1.STEEL ag,3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.fINKNOWN [I99.OTHER S 44a <br /> SECONDARY CONTAINMENT ❑ 1.8TEEL 3.FIBFAGLAS S ❑ 6.EXTEFLIORMEM13RANELINFR ❑ 7.JACKETFD 445 <br /> ❑ 90.NONE 95.UNKNOWN ❑99.OTHER5 ): 4454 <br /> OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑I.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 4W <br /> SYSTEM TYPE I.PRESSURE ❑ RAVTY 3.CONVENTIONAL SUCTION ❑ 4.SAFESUa�lON[23MR§2636(.x3)j 458 <br /> PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE U 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT 0 1.STEEL L*4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGID PLASTIC 4Mb <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464 <br /> PIPINGT'URBINE CONTAINMENT SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL <br /> ❑ 90.NONE 4Nd <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS U IO.RIGID PLASTIC Ll 90.NONE 99.OTHER(Specify) 464 <br /> 4641 <br /> VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC Ci 90.NONE 0 99.OTHER(Specify) 464f <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL EO 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4Ug <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL EA 4.FIBERGLASS13 10.RIGID PLASTIC U W.NONE 9976THER(Speclfy) 4616 <br /> 46 b1 <br /> VENTPIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 2.DOUBLE WALL d29 90.NONE 4641. <br /> RISER PRIMARY CONTAINMENT I.STEEL U 4.FIBERGLASS U 10.MGM PLASTIC Ll 90.NONE 0 99.OTHER(Specify) 164j <br /> RISER SECONDARY CONTAINMENT 1.STEEL A 4.FIBERGLASS 461'1 <br /> 10.RIGID PLASTIC 90.NONE 99.OTHER(specify) 4Mk <br /> 464k1 <br /> FILL COMPONENTS INSTALLED11I.5PILLBUCKET IQ 3.STRIKER PLATEEOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. <br /> VII.UNDER DISPENSER CONTAINMENT <br /> CONSTRUCTION TYPE L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS <br /> CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER IS 'fy) ❑ 'NONE 9` <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information Provided herein It RIM%accurate, <br /> and V full com Lance with legal requiretimirats. <br /> APPLICANT SIGNATURE DATE 2 L/ 470 <br /> APPLICANT NAME(print) 471' APPLICANT TITLE y n R 4n. <br /> UPCF UST-B-1/2 <br /> Rev.` <br />