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943/0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM �J �,r�a•V�S� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Checkone nem onh•. For o DST closure or removal,complete onh'this section and Secnonar I,Il,HI.11'.ondLY belong 436 <br /> ❑ L NEW PERNff7 ❑ 3.RENEWAL PERMIT ❑ S.CHANCE OF MFORMATION <br /> 6.TE KIPOILARY LIST CLOSURE 7.UST PERNIANENP CLOSC3RE ON SITE D &UST REMOVAL <br /> DATE LIST PERhLANENILY CLOSED: 43a^ DATE E.ITSTING UST DISCOXTAED: +?'6 <br /> L FACILITY INFORMATION <br /> FACILITY ID a C4gemy Use Only) _ <br /> BUSINESS NAME(Same as Fac Meme orDB.l—Doing Bus s . 1 3 <br /> i✓illil //1� <br /> BUSINESS SITE ADORE 10i CTI1' I'U <br /> H. TANK DESCRIPTION <br /> TANKIDr + J32 TANK hLANITRACT TCR +?3 T-ANk CONFIGURATION:THIS TANK IS +34 <br /> a oS/S L/'«y ❑ I ASIA D,-AD VETANI: can�ldr.,,r ash <br /> TXi gNr. v- CAIN A 04,1P.IRT104TEDUNIT eoapausual duaat <br /> DATE IF SY STEhI ST.ALLID 43` T.ANK CAPACfTY IN G.ALLONS 434 NjljjEER OF COMP.aRThIENfS IN TIO?UNIT J3_ <br /> o <br /> III. T USE AND CONTENTS <br /> TANKUSE 1a MOTORVEHICLEFUELING ❑ lb.MARINAFUELING ❑ le A\TATTONFUELIING 439 <br /> �3.C1I@.HCAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Oadods Usd W) ❑ 5EMERGENCY GENERATOR FUEL IMC <(c 1] <br /> ❑6 OTBER GFNERAT,:,R FUEL ❑ 9i 13NI.-N I\N ❑99 OTHER(SpwAyl 43% <br /> CONTENTS PHfROLHImf ❑ la DIEM. <br /> AR UNLEADED ❑ 1 ET FITADH LNLEADHD [1 6 A%-kn(-N L3NI.E-1DID <br /> ❑ ?DIESQ. ❑ i NET FUEL. 6 At7AIIO1.I G.AS <br /> ❑ R PETROLEUMBLENOFLIEL ❑9 OTHER PETROLEIml(SPM*) 44a <br /> NON- _ _ - - __ -- <br /> rFrxc�ml ❑ 7 L35EDtW. ❑ I0 Erxw,:,L . -- <br /> 11 OTHERNON-PECRi,LELmNtS ,h, 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1.SINGLE R'ALLIN I BLE 11 ALL ❑ 9, 1NIN, WN -.__ -_ _-. 43 <br /> -_ --- - - <br /> PRDsLARYCIDNT.AINb�N'T I STEEL3 FIBERGLASS ❑ 6ISTIItNAI BLADDER -- -- 444 <br /> 9 7 STEEL+INTERNAL LIRNG ❑ 9S CTANOIAN _❑ 99 OTMM(Sp afy) Ott <br /> SECONDARY CONTAINMENT ❑ 1 STEEL. q3 FIBERGLASS ❑ 6.E1'7ERIORIvIE BRAIMLINim ❑ HIED <br /> 7IACK44! <br /> ❑ 90 IF VE 95 UNKNOWN ❑99 0MER(SpreiR'1 44ta <br /> OVERFILL PREVENTION ❑ 1 AUDIBLE S\ISUA'L ALARLLSBALL❑ =BALLFLOAT a ENGTL SHIlFFr <br /> 3 <br /> 4 TdD :hE5AEC7tEl@NISFORESEh¢IONFROhfOt7PRElMO,NH"L3PhEN <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ I MINGLE WAll R 2 IXILBLE WALL ❑ 99.tMIER <br /> —__— - <br /> SYS1EI11 TYPE [$I PkF,SS73Ft[ GRAtTTY ❑ 3 (\JN4TINfIONAL 9Jl'[f(1N ❑S 436 <br /> PRIMARY Ct WT.AWhIF.NT ❑ 1 STEEL �4 FIBERGLASS FLEXIBLE <br /> ❑ 8 E310 RIGID PL.4.STTC 464 <br /> ❑ 90 NONE _ 93 UNKNOWN ❑ W 4)11111R(Sp_ecdy)- <br /> SECONDARY CONTAINAR?NT ❑ 1 STEEL hl OHBHRGLASS ❑ R FLESB3LE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ sX,NONE ❑91 UNKNOWN ❑ 99 OTTIER,Specdy) 461a <br /> PIPING TL7CBINE C()Nf.A[Nm2NT SImIP T1"PE 1 SINa:A[t =I>t STELE AL <br /> _MM ❑ 90 NONE 461d <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRDdARY CONTAIINENT ❑ 1 STFFL 1p 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.N01JE ❑ 2> 'iTTBR 3Spegfi� e3 <br /> VENT SECONDARY CONTAMIENT ❑ 1 STEEL bg 4 FIBERGLASS — _- OTHER <br /> ❑ 10 RIGID I4.ASIIl' ❑ 90.NONE ❑ 99 93 iSpecdyl J6� <br /> VR PRDAARY CONTAINMENT O 1 STEEL 1p J FIBERGLASS ❑ 10 RIGIDPLAMC O 90 NONE ❑ 99.OTHER(Spccdy) <br /> VR SECONDARY CONTAINMENT ❑ 1.STEN. Ej 4 FIBERGLASS ❑ 10 RIGMPLASTIC ❑ 90.NONE ❑ 99 OTIIFR(Sp.*). 4a� <br /> VENT PIPING TRANSITION SCAMP TYPE ❑ 1 SINGLE tVALL '_DOLBLH WALL ❑ 90.NONE <br /> RISER PRIMARY CONTAINMENT 'Fj 1 STE33L ❑ 4 FIBERGLASS ❑ 10 RIGIDPLASTIO ❑ 90 NObW ❑ 99.(THER(SpeOdy). 4" <br /> RISER SECONDARY CONTAINMENT ❑ 1 STEEL �4 FIBERGLASS ❑ 10 RIGIDPLASDC ❑ 9f?NONE ❑ 99.OTMM Spesdy). <br /> _ J64I <br /> FILL COA]PONENTS INSTALLED I SPILL BUCKEf IR I STRUM PLATE B,TP hIPRl,TF(TOR 18 4.CONTAINh1E14T SM" - <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRITMONTYPE ❑ 1 SINGLER:ALL _ �' DURLER ALL ❑ 3N,)DISPENSERS ❑ 90 NONE +49•' <br /> CONSTRUCTION MATERIAL 01.STEEL 4.FBHRGI.ASS 0 1 RIGID PLASTIC ❑99.OTHER(Spxify) u <br /> VIIL CORROSION PROTECTION <br /> STEEL CMIPONENT PROTECTION 0 : SACRITCIALAAN':'DE(Si 4 11,1PRESSED CURRENT 4iIScC-MN 4+a <br /> IX. APPLICANT SIGNATURE <br /> CERTMC.ATIOM 1 cern _ th t this USTsxtem is compat' le with the hazardous substance stored and that the information pmkled herein is true, <br /> a <br /> soomra d in full ram li a' e a uirements. <br /> APPLICANT SIGNATURE DATE A `S ® '-o <br /> APPLICANT NAME(pmt) ,�kC4-3 .1APM.II'.ANT t 4-2 <br /> 2 wwn <br /> UPCF UST-B Ree.(12J2W7)-1 .\\�U��NJ 5f complete <br /> 10 <br />