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bPW)GRAM CMSOLMATED FORM
<br /> UMMMOM STORAGE TAM
<br /> 0P=AMGPERMffAffUCA170N--TANK O TION One t;-
<br /> TYPE OF ACTION oae((em may. For an UST pammmit elm=at may ibis sec6on and Seedum 1,n,Ill,IV,mid JX below) 4N
<br /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION
<br /> b-TVAMRARY UST CLOSURE I.UST PERMANENTCT OSU1tE ON S Q 3,UST RIU40VAL
<br /> DATE UST PERMANENTLY CLOSED: DATE EXISTING UST OISCOVEREA: 43Wr
<br /> }ext ":>;w:�i�iii:�:,:?:yd•.:::,•,y:�j' ...
<br /> '..r. s;�•. c.��: r: a 171�.•�''^i�f.' „'i'ar�; '... ..,.;5>r.a"S," �i�,•i'
<br /> '; : '::r. r.,.',s:.i'.'r. '...' ;,tk�it a;?��� *, R� .H.1r q� ,ri'�' .,�e;d.:'•.,�:.ay...f„nt:r',..�,.. .eu.,.:,.r. ,aG;=- .,.i��J.>:..
<br /> ''tr; .4•:..+•,ur....(":a i.'�l., 1r�J4a7G IR r,3'.%',
<br /> FACILITY ID#VRmcy Use 0*)
<br /> eg;
<br /> BUMMS N (Sme as FACILITY NAME or DBA-Doing 13mdmms As) 3
<br /> BUSINESS SITE ADDRESS �- ® Iw CTTY 104
<br /> 1QOTANK ED# 432. TANK MANUFACTURER 4314 TANK CONFRIURATION:TM q TANK 15 434
<br /> ❑1.A STA TANK
<br /> Q 2.ONe IN A COMPART149MM UNIT.
<br /> commmeamp"rein ae
<br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS Q6 NUMOW OF COMPARTMENTS IN THE UNIT 437
<br /> • ';"•r••r.t , .. ::1111 : :. ... :•.. a•'+L r;.�.r,-�iKo+,.`w"trai�3.,,Ali,:�.4:.d�:a.-:��:'��.°:+''C�.,a'i'.
<br /> .. .. ..,,i .. .. ..... ..:.1:111 . .• . .. .. - .. .:.,,;.;
<br /> TAMC USE W 1a.MOTOR VEHICLE FUELING ® lb-MARINA FUELINO ® Be•AVIATION FUELING 434
<br /> ❑3.CHEMICAL PRODUCT STORAGE ®4.HAZARDOUS WASTE Mt&dm Umd OR) ®s.EmEROF«NCY GENERATOR FUEL(mc¢2 81.5(41 4;%® 6.0tII»OL'NERAIORFt1Ea. ® 95. ❑99.
<br /> OTHER LSym
<br /> CONTENTS PETROLEUM: 13 1 a.REGULAR UNLSADLD C3 le,MIDORA UNLEADED d Ib UNLEADED 440
<br /> D 3.DIESEL ❑ S.JET FUEL ❑6.AVIATION GAS
<br /> ® R-PrmOLEUM BLm FUEL 0 Q.OTHER PETROLEUM 3 44th
<br /> NOMPE7'ROLEUM:❑ 7.U$ED OIL ❑ 10.ETHANOL
<br /> 11.VMWk NON-nrI`ROWUM 4
<br /> :•,' :'
<br /> TAW
<br /> 00"nkYk,'�'<.t:, ai.wi``• ''`�,•'aRyvb .'�:r;i' r^;�-'."4:'.'iC ,�rw.,
<br /> TYPE OF TANK L SINGLE WALL 2.DOUBLE WALL95 443
<br /> PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 3.FIBERGLASS El b.INTERNAL BLADDER 444
<br /> 7.STEEL+INTERNAL LINING ® 95.UNKNOWN ❑99.OTHER (SocOM. 446
<br /> SECONDARY CONI'ALNMENT Q 1.STEL IRA"WWLASS ❑&EXTERIORMEMBRANSLINER E3 7.IACXFMD 495
<br /> 90.NONE 93. 99.0 MER44%
<br /> OVERFILL 1.0-DW-2&VISUAL U h 2.EAFLOAT 3.FM_TUBE SHUOPF VALVE 452.
<br /> ❑4.TANK MEETS REOUREMENTS FOX13xZMrWN FROM N
<br /> PIPING CONSTRUCTION -WALLED 3.DOUBLE-WAUM ❑99.OTHER 4�
<br /> SYSTHM TYPE 1. INGLURE 2 GRAVELY 3 C ONAL SUCTION ®4.SAVE SUCTION M3CCR 3 �
<br /> PRIMARY CON'TAINMCNT O 1.STEEL %iP4.Fm ERGLASS ❑ &FLEXIBLE 10.RIGID PLASTIC 464
<br /> ® 90.NONE Q 95.UNKNOWN D".OTHER 4640
<br /> S9CONDARY CONTAINMENT ❑ 1.STF.RL P4.FIBERGLASS 13 8. LE 0 I0.RIGED PLASTIC 4Ub
<br /> 13 90.NONE ® 95.UNKNOWN ❑ 99.2Tl0(S )
<br /> P M CONTAINMENT SUMP TYPE 0 1.SINGLE WALL ❑2.DOUBLE WALL. 90.NONE 464d
<br /> 1111, .":......, ,.,,•.. yam,, moi, �+�7 Vis}
<br /> •,•,4✓,';c�,h`;i�tr�.t:1:?,,-'d �i-'�"gr�A+ g3�� sem^• 'fit lr.`G; �a.'A., :sk"?"`%':=.J:'.'3r;�Att�':
<br /> •:... .,:.�:.:;.,111_1,,• .,
<br /> ...�. :. '. ... .•. 1111 ..-. ... 1111:, :... ._. ....•. ...
<br /> VENT PRIMARY CONTAINMENT U 1.STEEL 4P4.FIBERGLASS U 10.RIGID MASTIC El 90.NONE 0 99.MUM(SPOW 464c
<br /> I
<br /> VENT SECONDARY CONTAINMENT L3 1.STEEL 4.FIBERGLASS El 10.R1QW PLASTIC 0 90.NONfi 99.OT•IdEit(Sp.*) 400
<br /> 40gf
<br /> 4698
<br /> VR PRIMARY CONTAINMENT U 1.STEEL. T FIBERGLASS 10•RIGID PLASTIC 0".NONE ❑99.OTHER(Spedfy) 4mg
<br /> 9 4
<br /> VR SECONDARY CONiA1NhIENT 13 1.STEEL a FIBERGGA3310.R1610 n ASTrC 13 90.NONE 13 99-GTti2R
<br /> 4661
<br /> VENT PIPING TRANSITION SUMP TYPE Ell.SR4=WALL 2.DOUBLE WALL 40.NONE 464L
<br /> RISER Y CONTAINMENT 0 1.STEEL y 4.FIBERGLASS 10.RIGID PLASTIC U 90.NONE U 99,OTHER(Sp&clfp) 4"
<br /> 4541
<br /> ROM SECONDARY CONTAINMENT U 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NONE 13 99:OT14ER'(SPadfy) 460
<br /> 4601
<br /> FILL COMPONENTS INSTALLED 1.SPILL BUCK@T 3.57ItIKER PLA PROTECTOR 4.CONTATNMENT SUMP 451&4
<br /> - H:... ;Irl:;;:�':�1�'•Sa�R;"t�l,,.wi.ea;':'d••, l °�,IfgV '� °.1;F.�h"`'t';�'r:.td..yy�ir:7"'Cc'''s"•'�.I'a�,:.'�'k+'.'•'r,.:,�.,•
<br /> cQNSTRLrr
<br /> ,1,111
<br /> .:' :• .. ::�.. '•t,,.'?..}4,.. r•:::•:.,::,.-. •111:1: �"... a' 111$1. ,.k .+..
<br /> WN TYPE ® 1.SINGLE WALL 2,DOUBLE WALL ®3.NO DIUM43M ❑90.NONE 46..
<br /> CONSTRIXIION MATERIAL I.STEEL, AiV4.FIBERGLASS El IO.RIGID PLASTIC E3".On=( 469D e
<br /> .r.>... '.a,ri;, rna,,, .�.. r.�rp.r•.,•ssr,rt;• .�.e,q;a�'.. ,.,I,.: ;.garb,">�.; ,,�•� ap;> ,.a-;,'a•;::
<br /> 11,1:1• T:.ii 4:
<br /> _
<br /> STEEL COMPONg"PROTECTION [32.SA ANODEANT •6.1SOS) ❑4.IMPRESSED CURRLATION 446,
<br /> CERMCATION.I cer ft that this UST systemis copgmdble wft the z tmS mbgbmt fMnd mx{that ft fthandon� ed Im"M LS Mhvc,4
<br /> and to lull. mx 1
<br /> °
<br /> APPLICANT SIGNATURE: G DATE
<br /> APPLICANT NAME( tJ�u,�( �� l 471 APPLICANT -700'.'LE �°
<br /> UPCv UST-B-1/2 Rev.p
<br />
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