BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

RECEIVED UNJFJED PROGRAM CONSOLIDATED FORM 1 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATIONi��Yrt Qt TYPE OF ACTION (Check one item only. Foran ST permanent closure or removal,complete only this section and Sections I,II,11 1,IV,and ° 'al T4;0 ❑ 1.NEW PERMIT Ly"3.RENEWAL PERMIT ❑ $.CHANGE OF INF'OR.N A.TION ❑ 6.TENTORARY UST CI OSURE ❑ 7.UST PERMANENT CLOSURE ON SITE, ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430' 1 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION, rACIL1TY ID 4(Agency Use Or:4) _ 1 BUSINESS NANIE(Salne as FACILITY NAME or D13A-)Doing Business As) 3 ►4 S N r 6 BUSINESS SITIADDRESS 103 CITY 104 II.TANK DESCRIPTION. TANK ID# 472 TANK MANUFACTURER 413 TANKCONFiGURATION: THIS TANK 1S 434 A STAND-ALONE TANK ©2.ONE IN A COMPARTMENTED UNIT, Comvieb one page 2r ca.:h com anmmt in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT oat $ 0 or) III.TANK USE AND CONTENTS TANK USE la,MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ !c.AVIATION FUELINGI 439 ❑ 3,CHEMICAL PRODUCT STORAGE [14.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL V53C§26181.5(e)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)! 439a CONTENTS PETROLEUM= ❑ 1a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Jb,PREMIUM UNLEADED 440 C 3-DIESEL ❑ 5,JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM S ci ; 4400 NUN-PETROLEUM-❑ 7.USED OIL ❑ 10.ETHANOL ❑ i].OTHER NON-PETROLEUMS eciry; 4406 IV. -TANK CONSTRUCTION TYPE OF TANK I.SINGLE WALL gj<.DOUBLE WALL C] 95,UNKNOWN 4a3 PRIMARY CONTAINMENT ❑ L STEEL ®'3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7,STEEL+INTERNAL LINING ❑ 95,UNKNONVN ❑ 99.OTHER (Specify); 4440 SECONDARY CONTAINMENT ❑ 1.STEEL Er.FIBERGLASS ❑ &EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 443 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify); 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT FILL TUBE SHUT-OFF VALVE 452 ❑ 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1,SINGLE-WALLED -53U-BLE-WALLED ❑99,OTHFR, 460 SYSTEM TYPE En.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION Iz3 CCR§2630(0)(3)1 458 PRIMARY CONTAINMENT ❑ 1,STEEL 4.FIBERGLASS ❑ 9.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 5.TINKNOVN ❑ 99.OTHER(S eciR,): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ lo.ItIQLD PLASTIC 4646 ❑ 90,NONE ❑ 95.UNKNOW?] ❑ 99,OTHER(SPe-ify): 4640 PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL Q 90,NONE 46ad VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIP EP)(PING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90,NONE ❑ 99.OTHER(Specify) 4644 464e1 VENT SECONDARY CONTAINMENT I.STEEL 4,FIBERGLASS ❑ lo.RIGID PLASTIC 90.NONE 99,OTIIFR(Specify) 464f 4644 VR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ W.RIGID PLASTIC 0 90.N__0_N_E__n 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS Q 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE El I.SINGLE WALL M 2.DOCBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC U 90.NONE ❑ 99.OTHER(Specify) 4644 464'I RISER SECONDARY CONTAINMENT 01.STEEL ❑ 4.FISFRQLASS 10.RIGID PLASTIC ❑ 90,NONE ID 99,OTHER(Specify) 454k 464k1 PILL COMPONENTS INSTALLED 1.SPILL BUCKET 23.STRIKER PLATE"BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 we VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL E] 2.DOUBLE WALL ❑ 3.NO DISPENSERS d 90.NONE 46N CONSTRUCTION MATERIAL ❑ 1.STEEL K4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 0.OTHER(Specify) 469b< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6,ISOLATION 446. LX. APPLICANT SIGNATURE CERTIFICATION: t certify,ththis UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full oce with legal requirements. APPLICANT SIGNATURE DATE 4r0 APPLICANT NAME(pr tQ 4t1 APPLICANT TITLE 472 I lC 11�9v`t d H Gd UPCF UST-8-1.12 Rev.(12/2007)