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MEN <br /> WbNRUED PROGRAM <br /> A <br /> UNDERGROUNDO TANK <br /> OPERATING PERMIT APPUCATION-T N(One form Per UST) <br /> TYPE OF ACTION (Check one'ficat o* For an UST pamancot closure or rarmovak convicte only this secbm and Sections L q III,TV,end IX Wow) 4� <br /> ❑ 1.NEW PERMT ❑ 3 RENEWALP 5.CHANGE OF INIFORMA11ON <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 &UST PJEWVAL <br /> DATE USF PERMAIqENTLY CLOSED: 43M DATE EXISTINGUSTI)MCOVERED. 4 <br /> I. FACHITY INFORMATION <br /> FACILITY ID€I(Agency Use Only) <br /> BUS N ( as FAC or DBA Do' As) 3 <br /> sus / S SITE ADDRESS eo3Crz <br /> 104 <br /> IEL TANK-DESCREMON <br /> TAMC ID# 432 TAMMA14UFACTURM 433 TAW CONFIGURATION-THIS TANK IS 434 <br /> 1.A STAND TANK <br /> ❑2.0 INA= AR UNTr. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAmCITY IN GALLONS 436 NUMBER OF CO NTS IN THE UNTf 437 <br /> Opto <br /> HL T-AW-Ugg AM, CONTEM <br /> TANK USE Ia.MOTOR VEHICLE FUELING ❑ ib.MARINA FuELJNG ❑ ic.AviArioNFummo 439 <br /> 3.CHEMICAL PRODUCTSTORAGE [14. LIS WASTE OO) ❑5.EMERGENCY GENERATORFUEL(BSCt2 IA41 <br /> ❑6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑99. ( 4M <br /> CONTENTS PETROLEUM: to ED [3Ic RADE ❑ )h D 4u <br /> 3.DIESEL ❑5.JET FUEL. ❑&AVIATION GAS <br /> ❑8.PETROLEUM BLEND FUEL ❑ 9.OTHER PLrmOLEtjM 440a <br /> NON-PLTTROLEUM ❑7.USED OIL ❑ 10.ETHANOL <br /> 11.OTHER NO LEUM 4409 <br /> RNMUCnON. <br /> TYPE OF TANK 1.SINGLE WAIL. 2 LE WALL 95 UNKNOWN 443 <br /> PRIMARY CONT [I1.STEEL 3.FIBERGLASS ❑6.INTERNALBLADDER 444 <br /> ❑7.STEEL+INTERNALLINING ❑95.UNKNOWN 0".OTHER (Specify): 444a <br /> SECONDARY CONTAINMENT ❑ I.STEEL 0[3.FMERGLASS ❑&MnERIOR MEMBRANE L24ER ❑ 7.JACKEIW 445 <br /> ❑90.NONE gi 95.UNKNOWN 0 99.OTHER 445a <br /> OVERFILL PREVENTION Ll 1.AUDIBLE&VISUAL ALARMS L3 2 FLOAT 3.FILL TIME -OFF VALVE 451. <br /> ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. IT a:. - - OK-. <br /> PIPING CONSTRUCTION E-WALLED M Z.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE 1. URE 2 GRAVITY o 3. SUCTION 0 i.sAFERmfioNMEEREM45 458 <br /> PRIMARY CONTAINMENT 0 I.STEEL 0 4.FIBERGLASS ❑&FLEXIBLE 0 10,RIGID PLASTIC 464 <br /> 1390.NONE ❑95.UNKNOWN -❑99. ify): 464a <br /> SECONDARY CONT 1.STEEL. 4.FIBER ❑-8.nMMKE PLASTIC <br /> ❑90.NONE 1395.UN ❑99. ): 464c <br /> PIP INE CONTAINMENT SUMP TYPE 91 1.SINGLE WALL ❑2 LE WALL ❑90.NONE 464d <br /> VL VIM,VAJiOR-PECOVERY---(VR)-AND RISER/FILL PXPE-PlFiNG P-QNS <br /> VENT Y CONT I.STEEL 4.FIBERGLASS t0.RIGID 90.NONE 99.OTHER(Specify) 4&c1 <br /> VENTSECONDARYCONTAINMENT C3 E STEEL 0 4.FIBERGLAS io-RiGiDPLAsm N 90. - ) 4611 <br /> 464E <br /> VR PRIM1ARY CONTAINMENT IN I.STEEL 0 4.FTBEItGLASS 13 t0.RIGID PLASTIC r3 90.NONE 1399. ) 4618 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC IN 90.NONE ❑99.OTHER r4=*) 464b <br /> 4601. <br /> VENT PIPING TRANSITION sump TYPE 1.SINGLE WALL 0 2.DOUBLE WALL 0 90 464L <br /> PRIMARYRISER CONT I.STEEL El 4,FIBERGLASS El 10.RIGID PLASTIC E3 90.NONE E3 99 amm(Spa*) 464i <br /> RISER SECONDARY CONTAINMENT E3 I.STEEL 4.FIBERGLASS 10.RIGID P 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED ELSPILLBUCKET ElSTRIKEItPLATBIBOTTOMPROTECTORL MCCONTAINMENTSUMP 431" <br /> CONSTRUCTION TYPE M I.SINGLE WALL ❑2 LE WALL ❑3.NO DISPENSERS ❑90.NONE 4 <br /> CONSTRUCTION MATERIAL ❑ i-sTEEL FIBERGLASSt0.ttLGID PLASTIC ❑99. ) 46Wc <br /> ON. ' ON <br /> STEEL.compomwr PROTECTION E32.maumAL ANODE(S) 134 ED [36.LSDI ATION <br /> EL AMJCANT SHWATURE <br /> CATION:d mrtffy that dAb UST stared and that the Inf6ramation provided herein is true.a to <br /> jmQ in full compilanee with lead requiremats. <br /> 471LAPPLICANT SI DATE <br /> APPLICANT (Pt) - a! r 471- APPLICANT7AI 4a2 <br /> UPCIT .B.in oack Rev.( <br /> IMML <br />