COMPLIANCE INFO 2014 - 2015 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form UST) 'TYPE OF ACTION (Check uric item only. Foran UST permanent closure or removal,complete only this section end Sectiow f,li,DI,IV,and IX below) 430 ❑ 1,NEW PERMIT 0 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION Lj 6.TEMPORARY UST CLOSURE, 7.UST PERMANENT CLOSURE ON SITE 8.USTREMOVAL DATE UST PERMANENTLY CLOSED: 43' I DATE EXISTING UST DISCOVERED: /a 43% [. FACILITY INFORMATION A-D a-D 7 FACILITY ID q(Agency Use Only) '�Q-5J ) _ _ I BUSINESS NAME(Same w FACILITY NAMEorDBA-Doing Business As) s C,/ en -Sf<fc o / ;tr w r ¢<fe/Pi4.J4 yS�./�sfi<.f�.v.t'x iif✓. �.6/rr�•Fi..% BUSINESS SPIE ADDRES Im CITV 1 II.TANK DESCRIPTION TANK IDN 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS IJ4 � ASTAND-ALONETANK .ONE M A COMPARTMENTED UNIT. (4n/enaW .. A/W talo eo. Ibl wch eom emm16".H. DATE UST SYSTEM INSTALLED 433 TANK CAPACITY IN GALLONS 436 NUMBER MOP M THE UNIT m M.TANK USE AND CONTENTS TANK USE ❑ Ir MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 to.AVIATION FUELING 439 03.CHEMICAL PRODUCTSTORAGE n4.HAZARDOUS WASTE pndu ,e,Oj) ❑ 5.EMERGENCY GENERATOR FUELpm5C p52aLge)i 0 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑ 94 OTHER(S i ): 43%, CONTENT$ PETROLEUM: Cl Ie.REGULAR UNLEADED ❑ Ie.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED MD ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ B.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S i :(/ a 440. NON-PETROLEUM:�,7.USED OIL ❑ 10.ETHANOL ❑ 1L OTHER NON-PETROLEUMS i : yKp W. TANK CONSTRUCTION TYPE OF TANK 01,$INOLH WALL ❑ LOOUBLEWALL 095.UNKNOWN 4O PRIMARY CONTAINMENT ❑ 1.STEEL. ❑ 3.FIBERGLASS ❑ 5.INTERNAL BLADDER 494 13 7.STEEL+INTERNAL LINING ❑ 95:UNKNOWN 099,OTHER S SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBEROLASS ❑ 6.EXTERIOR MEMBHANELINER ❑ LJACKETED 445 ❑90.NONE ❑ 95.UNKNOWN ❑99.OTHER OVERFILL PREVENTION I.AUDIHLE&YISUALAlARM9U iBALL FLOAT El 3.FILL TUBESHUT-OFFVALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION PIPINOCONSIRUCTION ❑L.SINOLE-WALLED -L2.DOUBLE-WALLED 099.OTHER - 0p SYSTEM TYPE ❑ I.PRESSURE ❑2.ORAVRY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION p CCR f1m .X3R 455 PRIMARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS ❑ B,FLEXIBLE ❑ IO.RIOIDPLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTii sp d y µ4, SECONDARYCONTAINMENT Cl I.STEEL ❑4.FIBERGLASS ❑ B.FLEXIBLE ❑ I0.RIGID PLASTIC 464b ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER(S i woe PIPMOrI'11RBMECOMAMMENT SUMPTYPE ❑ LSINOLB WALL ❑ 2.DOUBL6 WALL ❑90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ID.RIGID PLASTICU W.NONE U.99.OTHER(Spegry) 464a VENTSECONDARY CONTAMMEM' U I.STEEL U 4,FIBERGLASS IO.RIGID PLASTICLl W.NONE Ll99.OTHER(Bocci ± 464e1 VR PRIMARY CONTAINMENT4618 ❑ i.STEEL U 4.FIBERGLASS 10,RIGID PLASTIC ,� �gW9,5•) 41a VOL SECONDARY CONTAINMENT - 4641 ❑ I.STEEL q,FIBERGLASS 10.R101D PLASTIC ;}I aOI: bp-5,) 44 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 4 4Mhl RISER PRI MARY CON TAM MEM' I.STEEL 4.FIBERGLASS IO RIGID PLASTIC 90,NONE 464L ❑ 90.NONE ❑ S 4641 RISER SECONDARY CONTAINMENT I.STEEL 4,FIBERGLASS IO.RIGID PLASTIC 4641 ❑90.NONE 99.OTHER(Spocify) 464k FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLA7SEOTTOM PROTECTOR 4.CONT t - 4Uk1 431. VII.UNDER DISPENSER CONTAINMENT(U I CONSTRUCTION TYPE U I.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DIS 4 ,NONE 4690 CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99,OTHER ) 469bo VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ L SACRIFICIAL ANODE(S) ❑4.IMPRESSEDCURRENT ❑6.ISOLATION III. UL APPLICANT SIGNATURE CERTTPfCATION: I certify that This UST system b compatible with the baardOw substance stored and that the infarmaHon provided hereto h frog aecuntq and in full com lienee wiM 1 aI r uircmevts. APPLICANT SIGNATURE - DATE /�-1 ^/y ria APPLICANT NAME(pr' ) 471' APPLICANTTITLE +12 re. ee . A17, ,Try/azp r UPCPUST-8- 112 Rev.(I Z/2007)