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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One toren usT w <br /> TYPE OF ACTION (Check one nem only. Fa an UST pummenmt closure or rctal.comPlde only Wis 9n CHANGE OF INFORMATION belmv) <br /> ❑ i.NI'.W PERMIT 3 RENEWALPE0.MIT g.UST REMOVAL <br /> 6 TEMPORARYUSTCI.OSURI'. T UST PERMANENT CLOSURE ON SITE awe <br /> no. DAH:EXISTING UST DISCOVERED. <br /> DATE UST PERMANENTLY CLOSED <br /> 1. FACILITY INFORMATION <br /> FACILITY ID N(Agency Use Only) - 5 <br /> BUSINESS NAME(Same as FACILITY NAME 3 a,A�DBA-Doing Bm.mm As) <br /> PFCl1 S FCAM `3`� a <br /> os CITY <br /> BUSINF_SS SITE ADDRF_SSy Seo(-, -( <br /> 11.TANK DESCRIPTION oa <br /> TANK ID UT TANKMANUFACIURER a35 TANK AONFlD-ALONEOUmTim NKTHITANKIB <br /> ®I A EIN A COMPARTMENTED <br /> C'•y yeR� S []2.ONE IN A COMMARTMENFRD 11N(f. <br /> M-6 all <br /> DATE UST SYSTEM INSTALLED 05 TANK CAPACITY IN GALLONS 456 NUMBER OF COMPARTMENTS IN THE UNIT <br /> 2,0 --C <br /> 111.TANK USE AND CONTENTS .39 <br /> ❑ 1a AYIATIONFUELING <br /> TANK USF. ® in MOTOR CHEMICAL <br /> ECTSTNG ❑ 10 MARINA FUELING 5.FMERGFNCYGENERATOR FUEL.ItIx 115MI NrlI <br /> ❑ J CHEMICAL PRODUCE STORAGE ❑1 HAZARDOUS WASTE Mdse.uW OiU ❑ a)o. <br /> ❑ 6 OTHER GENERA <br /> ❑TOR FUEL <br /> 95 UNKNOWN 13 99.0'1/1FR( ) .w <br /> CONTENTS PETROLEUM. ® Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED 06 AVIATION UM IAATONGSF.ADED ..� <br /> ❑ 3.DIESEL ❑ 5.JET FUEL <br /> ❑ a.PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM <br /> NON MTROLEUM❑ T USED OIL 10.EDIANOL cam <br /> 11 OTHER NON-PETROLEUM(SEE <br /> IV. TANKCONSTRUCTION <br /> TlT'E OF TANK I.SINGLE WALL 3.DOUBLE WALL ❑95.U}TKNOWN as <br /> PRIMARY CONTAINMENT i STEEL J.FIBERGLASS 6.INTERNAL BLADDER alae <br /> l STEEL-INTLRNAL LINING 95.UNKNOWN 99.OTTER w5 <br /> SECONDARY'CONTAR.MENT LSTEEL 133.FIBERGLASS ❑6.EXIERK)R MEMBRANE LINER LIACKEDiD a» <br /> [2 90 NONE 13 95 UNKNOWN 99.OTHER(OAT7.FILL LUBE SHAT-OFF VALVE 4m <br /> OV FRFILLPREVENDON I.AUDIBLE R VISUALAALLA FEZ HALL ON FROM OVERFILL PREVENTION EQUIPMENT <br /> ❑ 1.TANK MEETS REQU <br /> V. PRODUCT I WASTE PIPING CONSTRUCTION .eo <br /> PIPING CONSTRUCTION I.SINGLEDOU <br /> -WALLED 3. BLE-WALLED 99,OTHER .,1 <br /> I.PRESSURE ❑ Z.GRAVITY 7.CONVENDONAL SUCTION 1.SAFE SUCTION vCCR I'saM•M> a61 <br /> SYSTEM TYPE I.STEEL Q I. RAVITFIBERGLASS g.FLE7(IBLE 10.RIGID PLASTIC aaaa <br /> PRIMARY CONTAINMENT <br /> [3 90.NONE ❑ 93.UNKNOWN ❑ 99.OTHER( ). 10.RIGID PLASTIC a6ae <br /> SECONDARYCONTAINMEM 1.STEEL I.FIBERGLASS ❑S.FLEXIBLE .e., <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER( TY): 90.NONE alae <br /> WALL <br /> PIPINGM"IIECONTAMI wl7 SUMP TYPE <br /> I.SINGLE WALL 2.DOUBLE <br /> VL VENT,VAPOR RECOVERY(VR AND RISER/FILL PSE PIPING CONSTRUCTION .n5. <br /> VgNT IMARY CONTAINMENT I.S77P1 1.FIBERGLASS lO.RIGID PLSTIC W.NONE 99 OTTER fSpmly) .6N5 <br /> cat <br /> VENT SECONDARY CONTAINMENT I.STEEL /.FlBDIGLSS 10.RIGID PLSTIC 90.-N-0-NEIT99.OTTER(Spaelfy) a6Y1 <br /> asaa <br /> CONTAINMENT I.STEEL 1.FlBEROLSS 10.RIGID PLASTIC 90.NONE 99.OTHER(59edIY) will <br /> VR PRIMARY <br /> 1.FIBERGLSS 10.RIGID PLASTM 90.NONE 99.O71ERISpedyl a6rb <br /> VR SECONDARY CONTAINMENT I.STEEL aenl <br /> 1.DOUBLE WALL 90.NONE <br /> VENT RS <br /> PING TRANSITION SUMP TYPE I.SMGIE WALL eery <br /> i.STEEL 4.F®ERGLS 10.RIGIDS <br /> PLTIC 90.NONE OTHER(SPeuFy) 1 <br /> RISER PRIMARY CONTAINMENT <br /> a6rt <br /> RISER SECONDARY COJTEAB`1MENE I.STEL /.FIBERGLASS IO.RIGID MASTIC 90.NONE 99.OTHER(Spiny) a6Tt1 <br /> FBL COMPONENTS INSTALLED 1.SPR.L BUCKET 7.STRIKER PLATFIBOTEOM PROTECTOR <br /> A.CONTAINMENT SUMP 451. <br /> VII UNDER DISPENSER CONTAINMENT❑(UDC)DISPENSERg ❑90.NONE ase• <br /> CONSTRl3CElON TYPE a L SINGLE WALL ❑ 1a9P< <br /> CONSTRUCFlON MATERIAL L STFEI. 1.FIBERGLASS 10.RIGID PLASTIC 99.OTHER( <br /> YID. CORROSION PROTECTION <br /> STEEL COMPONENTPROTECTION ❑2.SACRIFICIAL ANODE(S) ❑ <br /> 1 IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX PLICANT SIGNATURE <br /> CERTIFICATION: I unify that th Yoe case th the Vardo`s nbstaKa Mred and that tk id*esat*a PM'ded beset"b W 'w"N"' <br /> madis M W8Y R 410 <br /> APPLICANT <br /> DATE 2. <br /> APPLICANT SIGNATURE a! <br /> an <br /> p1 n APPLICANT TITLE <br /> APPLICANT NAME(porn) <br /> UPCF UST-B-112 <br /> --- --- Scanned by CamScanner <br />