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96/10/2012 TUE 9108 FAX 705206 • ®003/905 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> NORMOP11 RATING PERMIT APPLICATION-WANK INFORMATION ola torn w Lim <br /> TYPE OF ACTION (Chaak ora itue only. Form UST pinenaamt mlDv or re111ova ao 0 only IME t 11,111,N,end Ul below) migiv <br /> ® <br /> I.NEW PERMIT 13 ].RENEWAL PERMIT ❑ &CHANGE OP INFORMATION <br /> 6.TEMPORARY UST CLOSURE 0 7.I*TP REMOVAL <br /> DATE USTPPRMANENTLY CLOSFA: DATE EXtSTINO UST DISCOVERED: <br /> PACG,TTY IDS(Ageway Use OAry) .� I�•. 1 •. :I <br /> BUSINESS NAME(Same ae PACHM NAME or DBA-DairM HIa51am As) <br /> ir1T�iaa011Od <br /> BUS STI'EAD I <br /> 12$0 N%1h WAsm Wa Stodkmu <br /> alliERM <br /> TANK IDM TW*1-Unleadto TANKMANUFACTURER TANKoONrIGORATKm:TWATANK IS <br /> ModemWa1diW ®1.ASTAND-ALONETAM <br /> fiq o S0 s 0:.0NEDIAC0MPARTMENTZ)UNIT. <br /> n1,41h IMF I <br /> OATR UST SYSTRIA N9rA-LW---4WC S NUM ER OP COMPARTMENTS PI THe UNU <br /> M1195 150DD L <br /> • • I' i i'� ! • I Fa }'r.l'• 'ill 4 ` .\,I i Ir,.`!.1.!i.V. 'I if•,Nry .N_' <br /> TANK 11&8 ` .Ia MOTOR VBBPMA FOBLJNG Ll 1b.MARINAMEILIM E3 Io.AVIAT70NFUSLINo <br /> O 7.Ck10A1CALPb0bUCt SYORA08 D 4.HAZARDOUS WASTE PNw.tr.ua alO 11 &MAERGENCY GENERATOR FUBLIHSC J=Ri s(.)1 <br /> D e.OYNaRO ERA R PLU 99. e19. <br /> CONTENTS P81'ROLBUM; UREOULAR UNLea Ia MIDORADSUNLEADED Ib.PREMILIMUM.3 Dnu <br /> D 1.D1mr. D 9.18T RRa. D 6.AVIATIONOAS <br /> C7 0,PDTROLBUM BLEND POOL 9.OTH8R PBTROIAUM f 410. <br /> NONd'aIRg911PA;D 7.Ua®OIL I D.ETHANOL <br /> WON <br /> U.O77iHRNON-PSTaOLEUM 'f aM <br /> ae4. <br /> TYPEOPTANK I.SINIMEWALL 12.DOURLBWALL Li 95,UMNOWN <br /> PffiZWYCONTAW04T RE I.Wrm U 3.FIBBROLASS U 6.M7AL D 4N <br /> 7.878Hi.a RMERNALLINING ❑ 91.UNKNOWN 9A OTHER /lr <br /> SECONDARY NMB 1, f.FIaMOLASS 6,aXTER10R M8p1ERANB LINaa 7.JACKBTBD k9 <br /> 9d NONE 97.lINKigWN 99.OTHBR i 4W <br /> O 1.A B V (ARMS 1.HAI,(,FLOAT O.P1LL e - P VALVE <br /> 4.TANK MEETS EMBN-IS POR BXBMPTION FROM OVERFILL PRBYWMN <br /> !PING '• 1,8MOLE-WALLED 2 DOUBL2,WALLBD 099.QTH8R 40 <br /> SYSTEM TYPE I.PRESSURE U 2.GRAVITY LJ 1 CONVENTIONAL SUCTION 4.SAFE SIR:IIW'1 Cdt 1 <br /> PRIMARY CC04TAIN BNT u L STIM 19 4.FIBERGLASS 0 9.FLEISIBiJI <br /> ld RI0lD pUarIC I <br /> NOW <br /> D 95.UNKNOWTI 99. .e.. <br /> SBCOMARYCONTAINMENT 1.6188E 4.F®HRQLA88 a�f1iKIELB 19.RRImPTA6rIC N <br /> 90.NONE 0 99.UNKNOWN 99.O17E R ai 4"PTEWII70R8iNS CI)WAINMHNT SUMP TYPE yIy.�6RI018 WALL 2 DOUBLE WALL 0 90.NONE <br /> VENTPRIMARYCOMAMMHNT 1,STEEL 4.FIBERGLASS IO.RBLDPLASI.IC 90.NOIR: 99.OTHER(Specify) 444 <br /> VENT SECONDARY MWFAUTZrr u 1. BL 1.P1BBWLAS6 10 JO.RMIDAXIMO.NO 99. (8paaifI Izmir <br /> y) <br /> VR MARY COWAIWENT 0 L STEEL 0 A FIBS t RI D ) <br /> mill <br /> AR'V ONTAMMBN't 0 1.WERL 99'I.FIRDROLAISS u 1 6 u W omit up_Wfry7__ <br /> VWT PIPWO TRANSITION PTYPIS <br /> RMW rRIMARYCO A 1.9788E 1 4,PIBSRGLAM 10.RBHDPLASDC 8 9d NONE u 99on=(hpoalg0 <br /> I <br /> NEER SWONDARY 650AMMISNT 0 I.8T0 gq N <br /> PSLCONPON8NT8 <br /> aV6YALL® n 1.aPILLHUCXBT 9.51'RIKHA PLATP/BOfI'OMPROTBLI" A CONIARiMEM SUMP 14S <br /> CON6TROQRONTYPS I.11DIM WAIL Q 2 DOUBLE WALL 0 9.NO VMPINSWs <br /> CON9'rRUL'1'WNMATBNAL 1.61881, 4.PID8RGLA6a 10.R30E1P !C0 P9. . <br /> 6f8HL COMPONBt!'1'PROTQCIION 1SACRIPR:fAL ANODS(8) � /.IMPABS38D CURRBNT D•d.L901ATION ' w. <br /> CERTIINCATIONt I <br /> earl], (het thN UST 4 11 IS oel7paRLle a Me hamardoal euhrtaeeo Hored mad(ILLI too M Mmes Provided hemik L ink Im ara[P <br /> ad In full a DR h 1 raghLremeat& <br /> APPLICANT SIGNATURE DATE 4 O <br /> APPLICANTNAME(plint) IogioderLal "• APPLICANTTfTI.E <br /> OparalOr <br /> UKF UST-8-1/3 Rev.(1217007) <br />