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IMMD PROGRAM CONSOLIDATED FORM
<br /> UNDERGROthD STORAGE TANK
<br /> OPERATING PERMIT APPLICATION--TANK INFORMATION(000 farm=UST)
<br /> YPE OF ACTION (Cluck one it=only. For an UST ciomm or removal,compere only this swtion and I,ll,Ili,IV,and Dr below)
<br /> T
<br /> PNEW PERMIT ❑ 3.RENEWAL PERMU [3 5.CHANGE OF INFORMA710N
<br /> 6 TEMPORAPY UST CI.EISURE 7.UST PERMANENT CLOSURE ON STTE L 8.UST REMOVAL
<br /> BATE UST PERbLANENTLY CLOSED: 45 DATE EM-1-ING UST DISCOVE12E1}_ 430b
<br /> FACILITY ID#(Agency Use Only) t
<br /> BUSMSS NA.MB(Same as FACUITY NAME of DB -I)oin names Asl )
<br /> HUSCiYEBS 31TE ADDRESS 1D P� 1 CITY C.[
<br /> TANK ID# 432 TAN$MANUFACTURER 433 TANK CONnWMATION:TMS.TANK IS 434
<br /> 01.A STAND-ALONE TANK
<br /> ®
<br /> 7-ONE IN A COMPARTMENT£I)UNTT.
<br /> dam
<br /> in am unk
<br /> DATE UST SYST'Elvi INSTAL L,ED ___41r TANK CAPACTPY IN GALWNS 06 NUMBER OF COIKPART'NtENfS IN THE UNIT d 437'
<br /> L /
<br /> TAMC OSE [J 1a.MOTOR VEIdTCLE FUF.1 A 3G ❑ 1 b MARINA FUELING I s.AVIATION FUELING 439
<br /> Q s.Cff&=AL l-R0D0CT STORAGE ,Q}4.13AZAADOUS WASTE tladWa Used Oil) C) 5.EA4MQbNCY TOR FUEL.{HSC$7$:9 toc)I
<br /> ® 6.0THER GENERATOR FUEL ®95.UNKNOWN Q 99,OT4YIE R 2maL439a
<br /> CONTENTS gEA'1tOLEUM: ❑ ia,REGULAR UNL!~ADbD © la I+IIDGRADE UNLEADED Q 16.PREMIUM UNLEADED 440
<br /> C3 3.DIESEL a 5,IDT'FURL ®6.AVIATION OAS
<br /> C# S.PEMOLEUM 13LM O FUEL 0 9.OnM PWMoLEUh4 S 4d0a
<br /> NON.PliTROLEUM Gr,USED OIL U l0.ETHANOL
<br /> I F,O'IL'IER NON-PEI'ROLEUM 441b•
<br /> TYPE OF TANK I.SINGLE WALL .0 a_DOUBU WALL 0 95.jjLWWN
<br /> PRWARY CONTAi ENt .STM Q 9.FWRGLASS E3 6.INTERNAL BLADDER 4a<
<br /> 7.STEEL+INTERNAL LINING ®95,UNKNOWN ®99.OTHER ): 40a
<br /> SECONDARY CONTA NMUNT ESTEAL Q 3_F SEEKL OS U b. OR MEMBRANE LINER 0 7.JACKETED 445
<br /> 13 94.NONE 95.UNIMWN CI�-OTHER 44U
<br /> OVERFILL PREVENTION ►.AUTaIBLE&V7SUALALARMS 2 AT U 3,FILL TUBE NWF-69F ViREVE 453.
<br /> (3 4.TANK MEETS" X1"MENT's FOR N FROM OVBRPILLPREVENTION ZOWMENT
<br /> ,:'-:.;;,;, •.:,. ... . .; :�:.,...:'`':.;'` fiFx:''F'RiO��I'�"rs-�';'9�"'P�7t�� (�':.�O1V5rTl� O�ia:':':`'`;:':--';. ,:'.
<br /> -PIPING CONSTRUCTION SiNGLP_WALbM Q 2.DOUBLE-WALLED 99.0THER
<br /> SYSTEM TYPE L PRE55CIRE 2.OP g 3.CONVENTIONAL SUCTION n 4.WESUMQNj23OCRHpy!o 458
<br /> M MARY CONTAINMENT 1.8TII;EI Ll 4,FIBERGLASS Lj 8.FLEXIBLE E3 14.RIGID PLASTIC 40
<br /> ©90,NONE O 95.UNKNOWN 0 99.OTHms000fy). 464e
<br /> SECONDARY CONTAINMENT L3 I.SML 4,FIBERGLASS 0 S.n ABLE !0.RIGID PLASTic
<br /> Q 90.NONE ❑95.UNKNOWN 0 99,OTFiBR(Speol , 460
<br /> PIP940MJRBM CONTAft"dWt SUMP TYPE i.SII ACiLb WALL ❑L DOtiBI E WAIL 90.NOMI
<br /> �� gpp gay �y may,
<br /> ,.. . ...... ....... a.:...
<br /> VENT PRIMARY CONTAINMENT Ll I,STES 0 4.FMERGLASS Ll 10,RIGID PLASTIC 0 90.NOME U 99.OTHU(Sped(/) 46401
<br /> VENT 9ECONDARY CONTAINMENT 1.STEML 0 4. -10-la= 13 90,NONE E3 99.OTItM(SiPOD*7) 4641
<br /> 464fl'
<br /> VR PRIMARY CONTAINMENT 1.STE 4,FLl3BROLASS 10,RIGID PLA YC .NONE 99.OTHER(5peci 1
<br /> VR SECONDARY CONTA06 ENT 0 1.STEEL M a.FIBERGLASS 0 It RIGID PLAST1r W NOnsE In 99.OT11ER(speer) 4%
<br /> pmt
<br /> VETT PIPING TRANSITION SUMP TYPE tl 1.$IN=Wj I.L 172.0MWALL 90.NONE 4ML
<br /> RASPA PRIMARY CONTAINMENT Li 1.ST09L 4.F(BERGUSS Ll 10.1KIDIDPLASTIC90.Nokm u 99.OTHER(Speer) �1
<br /> IUSERSECONDARYMN-rAIRPErT 0 1.STEEL El 4.PUMGLASS Q 10.RIGID PLASTIC 90,NONE 13 99.OTHER(Speplly)
<br /> FILL COMPONENTS INSTALLED 0 I.SMLI,5UCKE'T 0 3.9 P'LATEW PROTECTOR 4.CONTAINMENT SUMP 45lac
<br /> ::,:'.`'VII.'' . ER 1DISPENFA-'.C..' �P�N1►�1�.`:....
<br /> CONSTRUCTION TYPE Cj 1,WNULE WALL © 2.DOUBLE WALL CSI 3.NO DISPENSERS_ ❑ 90.NONE
<br /> CONSTRUCTION MATERIAL 1.STEEL 4. (BERGLASS 10.RIGID PLASTIC 99.OTHER $y 469o-c
<br /> .. .. ..'::,,.,.:i...•:i .: '.:.'. :.. i .'.;•P 1pis:'�.+Y� 101,'�rFi�V iL'L.�.'i�•a'N!.',.,..' .
<br /> STEEL COMPONENT'PROTECTION 0 2,SACRIFICIAL ANODE(S) (3 4.WRMRD CVRUNT 45 6.ISOLATION
<br /> . . �X;.�'FLr�:41�dTSICi�IaA
<br /> CEItT><pTCATYt3iV: Y that thh UST symm is compatible with the hazardous substame stared and that&e Infok latlatl prodded hetWA Is tree,amurate,
<br /> and in 6H caimpliampowlth hgal
<br /> APPLICANT'SIGNATOR£ DATE
<br /> ApFI_ICANT MAML(primp 471 APPLICANT TITLE /IS,. ).,,p/1 472•
<br /> UKF UST-0-f& Rev.(1E12007)
<br />
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