BILLING 2004 - 2011 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. Fm an UST permanent closure or removal,complete only this section and Sections 1,II,111,IV,and IX below) 430 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) ^ Msm 3 BUSINESS SITE ADDRESS X93 s�/y � " J `t 13.3a IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONPiGURAnom THIS TANK IS 434 O'n �`� 1.A STAND-ALONE TANK V" (_,Dl Y)�� 2.ONE IN A COMPARTMENTED UNIT. ee mie Reeecb mtheival. DATE UST Y INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 If Z III.TANK USE AND CONTENTS TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINAFUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE tImiWU Urea On ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 22 OTHER (S 'fy): 43% CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED (a Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 490a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS i : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN a43 PRIMARY CONTAINMENT ❑ L STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 449 ❑ 7.STEEL+INTERNALLINING ❑ 95.VNRNIOWN 99.OTHER (S : F P 444a SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ,❑ 7.JACKETED 495 ❑ 90.NONE ❑ 95.UNKNOWN 99.OTHER(S ): {sr{r 945a OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FBL TUBE SHAT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 123 CCR 1206(aX3)) 458 PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN CO 99.OTHER(SP ify): FRP 9b4a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN W 99.OTHER(Sp city):{'A*Q 461c KPING/rURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 469a VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT M L STEEL 4.FIBERGLASS ❑ 10.ALGID PLASTIC 0 90.NONE El 99.OTHER(Sp ify) db9c 961c1 VENT SECONDARY CONTAINMENT ® l.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify) 46it Wit PRAIARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464g 46 1 VR SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 4646 46 VEIN PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 0 2.DOUBLE WAIL 90.NONE 9691.1. RISER PRIMARY CONTAINMENT M 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC FU 90.NONE U 99.OTHER(Spectfy) 4Mj 46'1 RISER SECONDARY CONTAINMENT 1.STEEL C3 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 164k 469bi FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR a 4.COMAINMENT SUMP 451- VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE JEI 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 969+ CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 99.OTHER(Spenfy) 9696c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. UL APPLICANT SIGNATURE CERTIFICATION:I certify tlut this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fall com nee ith legal remairements. APPLICANT SIGNATURE / DATE _ - J V`' 4� APPLICANT NAME(print) 471' APPLICANT TITLE 4M. Ab4W UPCF UST-8-12 Rev.(11J2007)