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1123105 C <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Onefunis m 3STl <br /> TYPE OF ACITON (('heck one nem mmh% For a L ST clmare or remoral,complete ah this seen)and Secnamw 1,ll,111,17,and LY belmO 430 <br /> 1-NEW PERMST ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPINt.ARy UST CLOSURE 7.UST PEIRMLANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERhLANENTLY CLOSED: J1'" DATE E\7STING UST DISCOVERED: 4xn <br /> I. FACELITY INFORMATION <br /> FACILITYID«(Agem?,Use Onh•) <br /> BUSINESS NAME(Same as Faalte-.V nue orDR4ngBusmess. ) 1 <br /> C <br /> BUSINES —Da S ADDRESS „ I 101 1 CITY <br /> /yl <br /> H. TANK DESCRIPTION <br /> TANS ID= 132 TAI-a hLANUFACil1RER 411 TANG CONFIGUR.kTION:THIS TANK IS 411 <br /> S rna w �ST.IN A001NETTNI wuP Ne <P Fe far L <br /> ? iiF1E INA IYIMSARTAHNCID UNITvm <br /> DATE tTIT YS1Ehf ST.-1LLID 43` TAN:C. A=-INGALLONS 416 MTIBER OF CI AIP_WThIENTS INTHE CR1ff 41- <br /> /', e�+�O�f' � 0e'57 / <br /> III. TANK USE AND CONTENTS <br /> T.AFIF.CISE 16 In MOTOR VEECLE FUSING [I 1M MARINA FUELING 0 Ic AVLYTTONFLIELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE 04.HAZARDOUS WASTE(Imhdmlbd 0d) ❑3 EMERGENCY GENERATOR FLBL[BSC 3'-5-'Iv(01 <br /> _ 0 6.OTHER GENERATOR FUEL Q 95 UNLNORN _ _ 099 OTHERISpmd)_I. 43% <br /> CONTENTS PECROLELM pry Is REGULAR UNLEADED 0 Ic.MiDGRADELINLRADE) [3 It,PRE IUMUNLEADID i40 <br /> -LJ 3 DIESEL 135)ETFUEL ❑6.AVIATION GAS <br /> 8 PETROLEOMBLENDFGEL 0 9.OTHER PETROLEUM IS ') 419a <br /> NON-PETROLEUM 0 7 USED OIL ❑ 10 ETHANOL -- --- <br /> Il.OTBFRNON4VMOLB(IM(Specdt'). altb <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANS _ _ 0 1 SINGLE WAALL..13L2 DOLTBLE WALL ❑ 95 VNLNOwN u1 <br /> PRIMARY CONTAINMENT )$1 STEEL 0 3.FIBERGLASS 0 6 INTERNAL BLADDER 441 <br /> 0 7 ST'EE.+INTERNAL IRE4G O 95 UNKNOWN El 99 OTHER( ) 444 _ <br /> SECONDARY CONTAINMENT 0 1 SIM �a FIBERGLASS 0 6 0-JERIOR MEMBRANE LINER 0 7 TACLFIED 445 <br /> 0 90 NONE 95 tINI NOWN 099 OTHER( ) �a <br /> OVT.RFILL PREVENTION 0 1 AITIAB E R VTSLLAL.AL.ARhS 0 ?RALL FLOAT 3 F17S.TLBE SHLR-0PF V'vL\E 451 <br /> El 4 T.ANRMIEETS L7RE.IINTS FOR E%BIFTION FROh10l PREIT?NTIONB-L11PhlEJ'T <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> RING CONSTRUCTION Q 1 SINGLEB ALL '_13OUBLE A'ALL ❑ ) �:-TfIBR 4w <br /> SYSMIT'1TE _ PRESSLBE 2GRAkTTY r -NIENIT�.-N 1L SIIr 711.1 4SAFE,S[TCn CJ2 43S <br /> PRLMLARY CCINTAINMENT r_STEEL B 4 FIBERGLASS ❑ 1 FLEVELE ❑ 1 RIr3IDE.ASIIC 46'1 <br /> 0 90 NONE a 95 CRif.N(A N ❑ r) TRER rspe ,h, 464 <br /> SECONDARY L'ONI'ABIaENT 0 1.SLEET. 4 F1IN&NLA N ❑ S P,THER F ❑ 10.RIGID PLASTIC 4 <br /> ❑ 90 NONE 95 PC7FSIORN ❑ W i rTfIBg ISpeclh-r 454a. <br /> PIPING 7ITRBINE CONTAINMENT SCTP 7217E 13 1 SINGLE WALL =IN'LBLE VYALL ❑ ar NONE 46u <br /> VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRiM4ARYCONTABMENT ❑ 1STEEL ._W4FIBERGLASS OIo.RIGID PLASTIC O90NONE 099 OTHERRRSpeedg). ux1 <br /> VT?1T'SECONDABY CONTAINMENT OISTEEL R4 FIBERGLASS Oto RIGID PLASTIC O90.NONE 099.OTHER[specify). +6m <br /> VRPIUMARYCONTAHAffNP 0 1 STEEL -.I�t4 FIBERGLASS 0 to RIGID PLASTIC ❑ 90.NONE 0 99 OTHER(Spredy) - ) <br /> VR SECONDARY CONTAINMENT 0 1 STEEL 1*4 FIBERGLASS ❑ 10 RIGID PLASTIC p W NONE ❑ 99 OTHER(Specdy) 4us6t <br /> VENT PIPING TRANSITION SLUMP TYPE El 1.SINGLE WALL QI :D iLBLE WALL O 90.NONE <br /> RISER PRIMARY CONTAINMENT IF 1 STELE. 0 4 FIBERGLASS 0 10 RIGID PLASTIC 0 90 NONE 0 99 OTHERiSpeedyl 4" <br /> 1 <br /> RISER SECONDARY CONTAINMENT ENT ❑ 1 sT EEL F&4 FIBERGLASS ❑ lu RIGIDPL.ASTTC 0 9Rr Nf VE ❑ W OTHER i Sprcj�I <br /> FILL COMPONENTS INSTALLED I SPILL BUl7:Ff 3 STR11.ER PLATE B,TTi rM PRC,TDM rA IR 4 0 INT.AR,AIINT SUMP t� <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TATE ❑ 1 SINGLEWALL _ _ W11BLEVV'ALL [33 NO DISPENSERS _ Q9 <br /> -._ 0 NONE <br /> _-_ . _._ __Mr- _ 46x6 <br /> CONSTRUCTION MAI'F.RIAI. ❑ I STEEL 4.FIBERGLASS d lO.RIGIDPLASTIC 099.OTFffii(SpxiCy) ,wys <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECMON ❑ 2 S.V'RIFICIAL.ANi IDDS, ❑ 4 AIPRESSEDCORRENI' 6IS,:d.ATI(IN 44R <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify t this UST system is rompati)0a with the hazardous substance stored and that the information provided herein is true, <br /> acrvrat io fulLposs phuOw w1th o9emMts. <br /> APPLICANT SIGNATURE DATE C)CA <br /> APPLICANT NAME(pray ' t_3 1 APPLICANT TITLE 4- <br /> UPCF UST-9 Rev.(17200))-12 www.unidorsorg `l\j4� , e completed <br />