BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• C UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) TYPEOFACTION (Cbakom item only. Forms UST pmtClosure orrMovpl,mmplemazily ibis sutim-01111 Sectioas 11 H,ID,IV,ad lx below) 1.0 [] I NEW PERMIT ❑ 3.RENEWAL PERMTf 2-3CHANGE OF INFORMATION G TEMPORARY USTCLOSURE Q 7.USTPERMANENT CLOSURE ONSITE [18.UST REMOVAL DATE UST PERMANENTLY CLOSED: - DATE EDSTINGUSTDISCOVERED: ''0e . L FACE ITV INFORMATION - - FACaM ID#(Agaley Use U)V) - - BUSINESSNAME(Some as FACHXfY NAME or DBA-Doing Busiaesm As) // J BUSINESS SrrE ADDRESS Im cTTt61 Y � Z//.eST L�9n/c To C ids/ IL TANK DFSCRIP'TION - - - - TANK ID# TANK p6ANOFACTURE2 TANK CANFIGIJRATION:TB6TANKLS 'p4 ETA STAND-ALONE TANK /fin �I ❑?ONE INACOC9PARTN�N[IDUN[I'. y� v cure lined. m,le®r. �I� DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS alb NDAtBFROFCObIPARTMENTSINTT-ffi3INrf / aYi L/V II TANK USEAND CONTENTS TANK USE 19 Ia MOTOR VEHICLE FUELING ❑ Ib.MARINAFUMMO ❑ ICAWATIONFUELiNG 439 ❑3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE pv3o MWOR) ❑ 5.EWERGENCYGEMRATORFUEL(BSCVMIA9)I ❑6.OTHERGENFRATORFUEL [195.UNKNOWN ❑ 99.OTHER(Spec' ): 439+ CONTENTS PETROLEUM: ® Ia REGULAR UNLEADED ❑ IUMDGRADE UNLEADED ❑ ib.PREMRIMUNLEADED 440 ❑ 3.DIESEL ❑5.3ETFUEL ❑6.AVIATIONGAS ❑ RFETROI.EUId BLEND FUEL ❑9.OTiERPETROLEUM (Specify): 'bur NDN-PETROLEUM:ElI.UMM OE. ❑ 10.ETHANOL 11.OTHER NON-PETROLEUM5 - IV_.TANKCONSTRUCTION-. . - ... .. TYPfi OFTANK I.SINGLE WAIL EDOEMEE WALL El UNKNOWN - 1G PRMAIIYCONTAINIdENT 1_11.STEEL 3.FIBERGLA59 6.INIIItNA1.BLADDmt t+3 Q T.STEEL+MTFRNALf.INMG ❑95.UNIOIOWN ❑99.OTHER SECONDARY CONTAINMENT ❑ I.STEM. 3.FIBEfaGLA55 ❑6e[TERTORA BRANELINF1t ❑ 7.JACKfitm 115 11 ;0 NONE 95.UNKNOWN ❑99.OTEmRS OVERFILL PREVENTION 1.AUINBLEAVISUALA[AKMS U 2BALL17LUAT 3.FILL TUBE StM-OFFVALVE a5a ❑4.TANKMEETS UBEP.BNTS FORMMDir[ONFRDMOVMMUPREVENTIONEQUMENT v: PROOVCT/WASFE UC ❑ RiPIlbTGEONSfRUCTION PIPING CONSTRUCTION L SINGLE-WALLED I DOUBLE WAISFD 0 99.OTHER 460SYSLEMm I.PRESSURE ❑2.GRAVITY ❑I CONVENHONAL SUCTION ❑4.SAFE SUCRON OMt51636(aR3)1 464 PHIMARYCONTAMMENT U I.STEEL 4.FIBEROLASS ❑ 8.FLmaBLE ❑ 10.RIGIDPLAST[C 461 ❑40.NONE 95.UNKNOWN ❑ 99.OTTER(Speciry): 4643 SECONDARY CONTAINMENT - ❑ LSTEE. K4.FIBERGLASS ❑ BFLEMLE [3io.RIGDPIASNC e64a ❑ 90.NONE ❑95.UNKNOWN ❑ 99.0Timlt(Speerf•): 4 c M-INGITUIMM CONTAINMENT SUMP TYPE 1-3MGLEWAT.L ❑iDOUBLEWA 0",NONE _ 4396 VI:VENT,VAPOR;RECOVERY(VR)ANIDRUMIFILLPIPE PIPING CONSTRUCTION RM .. VENT PRRY CONTAiNMENr 1_STEFJ. a.FBERGLA55 ID.RIGxu I aTC 90.NOISE 99.OTHEt(Sp..W 45ae 96b1 VEWSECONDARY COWAINME'Nf O 1-STEEL Lj 10.MGM PLASTIC 90.NONE u 99.OTimR(Spmfy) 164E can vR PRGQARY CONrA1NAmNr 0 M-14ONE El 99.OTHETt(Specily) 131II VR SECONDARY CONTARHN NT 7 UI.STEII. 4.PIBEROLASS 30.RIGm PLASTIC 90.NONE 13 99.OTHER(Specify) a%n 1HM11 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 2.0OtBLEWALL AMNOM a4aT RISER PRIMARY CONTAINMENT I.STEEL U 4.FIBERGLASS su IO.RIGDFLm-m ❑90.NONE u 94.OTHER(spmfy) ^e1i 461'1 ItISERSECONDARY CONTAtNMEM LSTEEL 4.FRB7tGLASS 10. UGDPLASTTC 90.NONE 99.OTHER(Spairy) 4G6*1 FILL COMPONENTS INSTAUED 1.SPILL BUCKET IN 3.STRIKER PLATEMOTTOM PROTECTOR 114.CONTAINMENT SUMP 451a•c VII.UNDERDISPENSERCONi'AIl�MENT.(UDC) CONSL'AUCTIONTYPE 1.SINGLE E3ZDOUBLE WALE. ❑3.NO DISPENSERS [190.NONE 46%WALL CONSTRUCTION MATERW. ❑ t.ST'EFI. 4.F'BFR(R eccu 10.RIGID PLASTIC ❑99.OTHER( ' ) 469Sc VIII.CORROSION PROTECTION ST EEL COMPONENT PROTECTION ❑ 25ACRITCIALANODE(S) 04.RAPRESSEO CURRENT 6.ISOLATION 'b3. DL APPLICANTSIGNATUM CRRTIF[CATION:I c+U y Teat tlde UST.ys4 b®pstlbk wild d -mBefavice am,sd and tbat t a iofot>n n Provided 6eteim b tru4 accurate, and is rdl ca ITame 9R APPLICANT SIGNATUREME _ DATE t// / G j 4R APPLICANT NAW _ APPLICANT' LE Rev.(1212WI) UPCC UST-D-I/2