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UNIFFED.PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One fom per UST) <br /> .2 TYPE Or-A(C.MON (Chmkom-memamly I-or a UbTclawe or pvnpoval,cmiplete onry fiVs swfion and Sea* 111,771.1Y,amd1X below) 430, <br /> [] 1.NEW PERMIT 3.RENEWAL PERMIT EPTI&ANGE,OF INFORMA717ION <br /> [1 6.TEMPORARY IJST CLOSURE, 7.UST PERMANFNT CLOSURE ON SITE Q 9,UST kEMOVAL <br /> DATE YJST PERMANENTLY CLOSED: 430L DATE EXISTING UST DISCOVERED: 4Wb. <br /> FACn.TTY n> (.4png Um 04) <br /> BUSINESS NAME O�meas Fadlify N4mv orDBA-Dohm B=ws$Aj) <br /> mm� 'Oemat <br /> INESSEMADDRESS CITY lu <br /> e2A zo <br /> .......... <br /> 77: ........... <br /> TANK I 43Z TANK MANUFACTURER 431 TANK CONFIGURATION:THIS TANK IS 434. <br /> r-3 1.A STAM[>-ALONE TANK (:0d**kW*PWfiffa3& <br /> E3 2.ONE IN A COMPARTMEN`IW UNIT -AWu-,in ft mit <br /> DATEUST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS -436. NumBF.R OF commwrmEws IN mE UNIT A37. <br /> NT--- <br /> AM <br /> ............ <br /> TANK USE ,.rgrl&MOTOR VM(Mr FURI.ING [I 1b.MAKINA FUELING E) Ic.AVIATION F1j7ELTNG 4" <br /> 13 3.CHEMICAL PRODUCTSTORAOF. 4.HAZARDOUS WASTIS(Enduft und ou) Q 5.EMERGENCY GENERATOR RM p0C <br /> El 6.Ornim OuNERATOR FUEL 0 95.UNKNOWN 0.�9-OTIIER Sp2a 439L <br /> CONTENTS PETROLEUM:1 0 I;L REGULAR UNLEADED El Ic.)AIDGRADEUNLEADED E3 1b.PREMIUM EINLrADED <br /> 2-1-71DIMEL [3,5.jM_FUEL 0 6,AVIATION GAS <br /> L) $.PETROLEUM BLEND nJEL, 0.9.0-nirR PFFROLEUM @Pbay)r 440L <br /> N0N-PLrROLhU-M:Lj 7.USED OIL [3 10.hl"A-NOL <br /> 11.07MERNON-PETROLBUM(SpcOfy�. 440b <br /> .................... <br /> TYPEOFTANK [3 1,SINGLE WALL,,Ej.-�-.DOUBLE WALL 0 O.UMNOWN 445. <br /> PRIMARY CONTAINMENT 0 I-mm L) 3.POERGLASS [16.M. -ER-4ALBLADDEP <br /> +IN'IV.RNAI,,LINING [195.UNKNOWN E] 99.OTRER(SpBdfy), 444& <br /> Y C0NTAINMENTt-.e'1,)STE EL P, *­ff 7.JACKETED <br /> SECO�R- :&F.T�GLAiS 5 6.EXITRI - MEh0RANE LINE <br /> %430W.NONU. [3 95.UNKNOWN 0 99.0771FR(Specif . 445& <br /> y)_ <br /> OYr-"LLLPRFVENTION-'-"-----.�.AUDII�U&-'MU.A.L,OLL.,kRW -I!r2.BAI' TUBE SfiLrf'-OFF VAIXE <br /> L XFLOAT <br /> Ll 4A-ANK MkEIS REOUIREMENTS rOR EXEMPTION FROM OVERF11.1.PREVENTION EQUU-MENT <br /> .. ... .... <br /> PIPING CONSTRUCTION 0 UBLH WALL Q 99-an irp <br /> S 1 AL I)V(.MON <br /> YSTEM'TYPE I�j 1.'PRMkjRE 0 2.(;PAVrTY. 3,COII�TION i�iisu6l()N[7,- <br /> PRIMARY CO NTATNMENT 0 1.Sim J;r4.FI]SERGLASS 0 LF LMMLE 10.RIGID KASTIC <br /> 0 90.NONE 0 !2,UNKNOWN 0 99.OTHER(Specify): 464m <br /> SECONDARY CONTAINMENT 0 1.STEEL 0-4.FMERGLA&% 9,FLFXIBLE Ej 10.RIGID KASTIC <br /> L3 9D.NONE [j 95.UNKNOWN A9e-0-�*R(SP W M: 464............. <br /> PIPINrjnlj"TNE CONTAINMENT SUMP TYPE 0 i.smcm.WALL or'2.DOUBLE WALL El 90.NONE 4W <br /> ur <br /> VBNT PRIMARY CONTAINMENT C3 LS-11LEL r2e4.FIBFRG1;ASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTM(Speeify): 4"a <br /> 46401 <br /> VINT SECONDARY CONTAINmo-tr E3 1.S= wn. <br /> _Call.FIBERGLASS [1 10.RIGID PLAN-11C. [1 90.NONE 0 99.Omm(Smmiry); 4W <br /> VR PRIMARY CONTAINMEN1 b­I­&­11xL 0 10.RIGID PIASTIC [190.NONE [3 99.(yn[Fit(Spaefy): "aA <br /> 4%. <br /> 4661. <br /> VR SECONDARY CONTAINMENT 1.S MEL 4.FIMRQLA.1�1; 0 10.RX�11)PLASTIC 0 90.NONE 0 99,OTHER(Spcaify): <br /> .......... <br /> VENT PIPIN(j TRXNSMON SUMP TYPE 1.SINGLE WALL 012.DOUKE WALL E-3 90.NONE 4" <br /> RISER PRIMARY CONTAINMENT I�STF;f-3. ar4.rinuRGLASS Ll 10,-PJGID PLASTIC 0 90.NONr- [3 99.OTHER(Spocify),. <br /> RISER SECONDARY CONTAINMENT 1,8= Q4.ETELGI.; 10.RIGID IIASMC 0 90,NONE 0 99.OTHER(Spvmfy): 46a. <br /> �Ss Q 4640. <br /> F.I.LL C.OM.PON ENTS INSTA L.LE D I.Splu BjjCKh-r 3.STRW.-M.Z i..PLA-nwioTTOM PROTECTOR 0 4.(X.)NTAINMENT SUW <br /> 'Amb-6 <br /> L -u g.... <br /> CONSTRUCTION TYPE 0 1.SINGLE WALL Gr2.DOUBLE WAI�L [13.NO DISPENSERS 469tL <br /> CONSTRUCT70N MATERIAL El 1.STEEL V1.FIBERGLASS [3 10.RIGID ftAS7r1c 0 99.OTHER(Spooify) 46%L <br /> 46k. <br /> ...................... <br /> .................. <br /> STEEL COMPONENT PROTWrION [3 2,SACRIFICIAL ANODE-*�$) E3 4.IMPRESSED CURRENT 6.IWLATION <br /> ............ <br /> ........... <br /> . ......... <br /> CERUIFICATION:I certify thit 1his �Tsystem is qx*atible with the bmardous subsAuncc stored and th2t the Infonnatiou 1"W herein is t.,, <br /> accurate.a4A fj pj�l�th!Sg!!!requirements. DATE -4 470 <br /> APPLICANT!If!�� jVk.1 A - I - Jr.,/0-0 <br /> APPLICANT NAME(print) 'ZAJ2 In APPLICANT TM.E C-<C�o 47-1 <br /> d <br /> UPCF UST-B Rev.(12/2007)-1)2 wwwxuidocs�.� <br /> too/ toold OETZ# TZ:L0 90OZ/tZ/60 <br />