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-�� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> • UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (Onc form per usT) <br /> TYPE OF ACTION (Clrsck one item oaly. For a LEST closure or remmal,complete only this Suction and Sections 1,If,117.1V•and 1X below) 4N• <br /> ❑ 1.NEW PBWr ❑ 3.RENEWAT,PERMIT 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE.ON SITE Q S.UST REMOVAL <br /> DATE UsT PERMANENTLY CLOSED: a3oe DATE EXISTING UST DISCOVFRED: 430b. <br /> . _ <br /> FACILITY ID N(tswey(Ise Only) <br /> BUSINESS NAME(same as Faciiky Xwne or DBA-Dabw Dwinesa As) 3. <br /> �i <br /> ELI SWESS SITR ADDRESS l6s- CITY i 164. <br /> . .......:. <br /> :• .:. .. <br /> TANKLn;i 432. TANK MANUFACTURER 4;3- TANK CONFIGURATION:THIS TANK IS 434 <br /> O �6� u S (-r O 0 2.ONE tis A COMP,TANK <br /> UNIT �-ft uit <br /> DATE U <br /> SYSTEM WTALLUD 435. TANK CAPACITY IN GALLONS 431c, NUM13F.R OF COMPARTMENTS IN THE UNIT 437• <br /> . ....... ........ ...... .........,•:•:..:-.:.. .. _. . . .... .Q TETT..•-.,... <br /> TANK USE la.MOTOR VHHICLE FUELING ❑ Ib,MARINA FUELINGp lc.aV1anUN FUELING 439. <br /> • <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indwes umd oa) 0 5.EMERGENCY GENERATOR FUEL[WC.I252t1.5(e1J <br /> ❑6.01711:3tGENERATORFUEL _ ❑95.UNKNOWN ❑ 99.OnIFR(Spuxify} 4344 <br /> CONTENTS PETROLEUM: Arles.REGULAR UNLEADED Q lc,MIDGRADE UNLEADED-[3 ib.PREMIUM UNLEADED <br /> ❑ 3.Dumm. ❑ 5.JrT FUEL ❑ 6.AVIATION GAS <br /> Q &PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM(S 4404 <br /> NON-PETROLEUM:Q 7,USED OIL 0 10,ETHANOL <br /> 0 11.On Irit NON-PETROLEUM(S 44%. <br /> TYPE OF'TANK ❑ I.SINGLE WALL 2.DOUBLE WAL1-,_••-I7..95.UNKNOWN 443. <br /> PRD"RY CONTAINMENT ❑ i.STran. FIBERGLASS ❑6.INTERNAL SLADDF,.R . <br /> ❑ 7.STEEL+INI'WtNAL.LINING _ ❑ 95-UNKNOWN [399.UTIaER(SpoafyZ: 4440- <br /> SECONDARY CONTAINMENT El1.STL•EL R 3.Fm rLA.S.S (]6,EXTERIOR M M <br /> nRANE LINER Q 7,JACKETED "3• <br /> _ ❑ 90.NONE .0 95.UNKNOWN 0 99.OTHER(Specify): 4458. _ <br /> OVERFILL,PREVENTION .2T AUDIBLE&VISUAL ALARMS 2.BALL FLOAT _J;J'3.FILL TUBE SHUT-OFF VALVE 452. <br /> 4.TAA'K MEETS UIRE'.MFN`M OR EJ EWWN FROM OVERFILL PREVENTION EQUIPMENT <br /> PIPING CONSTRUC770N <br /> ---• ....__.❑ SINGLE WALL _2.DOUBLE WALL ❑ 99.or1741;R 46Q <br /> SYSTEM TYPE Gr_!,PRESSURE ❑ 2.GRAVITY _ p 3;CONVENTIONAL SUCTION ❑ 4.SAFE,SUCTION I23 Cat i1363ttax)j„• 452. <br /> PRIMARY CONTAINMENT ❑ 1.STFs.I. Rr 4.FIBERGLASS 0 S.FLEXIBLE ❑ 10.RIGID PLASTIC �• <br /> _ ❑ 90.NONE _0 95.UNKNOWN 0 99.OTHER(Specify): 464a. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 04,FInF.RGLASS ❑ 8.FLEXIIIIX Q 10.RIGID MASTIC' 46W <br /> __. 0 9o.NONE ❑ 95.IJNKNOwN 0_99.OTW if eou. <br /> PIPTNGfTURIANE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2,DOUBLE WALL. ❑ 90.NONr 464cL <br /> �{ .......,y....''f..�'........ <br /> U......... . ..''._ '.i 'i� '/,: ::� '-f•1r's t rX ::vt e3��( '.S 7 e•`iXT1'�'r"._.::::u.::•. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEW,-�s.F]BERGT:ASS ❑ !0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spa6 y): 16 edl. <br /> VENT SE(,'ONDARY CONTAINMENT ❑ 1.Snau. Pyo.FIBERGLASS ❑ 10.RIGID PLA.FnC" [190.NONE L] 99.OTHER(Spcti* 64 <br /> _ _..Ia <br /> VR PRIMARY CONTAINMENT - ❑ 1.S'fP.EL. e4-FIBERGLASS_ ❑"10.RIGID P1.A4TIC ❑90-NONE 0 99,OTHER(Spwify} �8 <br /> VR SECONDARY CONTAINMENT [J 1,ST Mi . 2r4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONR ❑99.OTHER(SPeafyk 4460. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ z.IX)URL.E WALL 0 90.NONE <br /> RTSFsR PRIMARY CONTAINMENT ❑ 1.STEEL Rr4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 <br /> RISER SECONDARY CONTATNMENT ❑ I.STEEL 4.FiBEFWLASS ❑ l o.,RIGID PLASTIC ❑ 90,NONE ❑ 99.(rITLER(Specify): 4644L <br /> FTLL.COMPONENTS INSTALLED Q 1,SPILT,BUCKET S.STRIKER PLATEMOTTOM PROTECTOR Q 4•CONTAINMENT SUMPVOW U <br /> 1a c <br /> :. <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL__ ❑ 2.DOUBLE WALL---... ❑ 3.N0 DISPENSERS ❑ 90.NONE 46`'8• <br /> CONgTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS l7 10.RIGID PLASTIC 0 99,OTHER(Specify) <br /> ;..:• ....,:•., •.'.;•..• `:'_....•, ...;..•. •.:>:•._. �•.;•fiM;�:'•i•l;;,V..JI?liCF3sw7�la�f�. �'i�v;RJ.ON <br /> STEEL COMPONFNT PROTECTION ❑2.SACRIFICIAL ANDD ©'4.IMPRESSED CURRENT 0 6.ISOLATION <br /> ;.. .. <br /> CERTIFICA77ON:I certify that this IJST 4yystem is coMatible with the harardeas substance Stored and that the information provided herein true <br /> acwratr.aad in f&omplian&with 1eP1 requiremenik <br /> APPLICANT SIGNATURE C <br /> DATE �oI o i70' <br /> APPLICANT NAME(print) `?t' APPLICANT 11TLE 40- <br /> XJPC F V4,rr-8Rvv.(1212007)-I2 www.unWemarg <br /> fi00/ Z00'd 0£TZ# TZ:L0 9002/tZ/60 <br />