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-{' <br /> UNIFIED PROGRAM.CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One Porn!per UST) `LD <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) <br /> ❑ L NEW PERMIT M 3.RENEWAL PEkml'l' _bJ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE, ❑ S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4WDATE EXISTING UST DISCOVERED: 430b <br /> FA!CILIT'Y;!tA <br /> FACILITY If.)fl(Agemy Use Only) <br /> BUSINESS NAM-.(Sa FACILITY NAME or DBA-Doing Business Aa) 3 <br /> {' V-% r- <br /> RUSINFSS SITE ADS 103 CITY 164 <br /> It TANK DE� RTP'I70N <br /> TANK ID# t 432 TANX MANUFACTURER 433 TANK CONF10LRATiom THIS TANK IR a,4 <br /> [11.A STAND-ALONE TANK <br /> � � <br /> ! /% 1 Q O 71 11,8Pf ONE LTJ A COMPARTMPNTfp LfNiT <br /> 1 Con =*ft PA.-%rvgKhce imtheunit, <br /> DATE.UST SYSTEM INSTALLED 435 TANK CAPACITY IN ALLONS 436 NUMBER OF COMI'ART'MGNTS IN THE UNIT 437 <br /> ANK...11 ANI_cO TENTS <br /> TANK USE )Zia.MOTOR V1,111CI.E FUELING ❑ 1b.MARINA FUELING ❑ 1..AVIATION FU6I.ING 439 <br /> L3 3.(:1 IRMICAL PRODUCT STORAGE El 4.HAZARDOUS WASTE(Includes Used oil) ❑ 5,EMERGENCY GENERATOR FUEL 93C.§25281.5(§)] <br /> ❑ 6.OTHER(iliNFRATORFUEL ❑ 95.UNKNOWN ❑ 99.O-rHL•R(Specify); 43 ft <br /> CONTENTS PETROLEUM: !a.REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑ Ib,PREMIUM UNLEADED 440 <br /> 3.DIESEL 0 5.JET FUFI. ❑ 6.AVIATION(IAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM S if : 4403 <br /> NON-PETROLEUM:❑ 7,USED on. ❑ 10 TTI(ANOL <br /> ❑ 11,OTHF,R NON-PFTROI,FUM $ pi ): 4406 <br /> :::. ...:,Elr':..;IA3VK:C:iEfNSI'RUC17EON <br /> TYPE OF TANK ❑ 1.SINGLE WALL .DOUBL.E WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ I.;;Trmn. .b1BER(iLAS.S ❑6.IN SILNAL BLADDrR 444 <br /> ❑ 7,STRF.,i;+1NTTRNAI,LINING ❑95.UNKNOWN [] 99.OTHER (Specify): 444' <br /> SE('ONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.IACKE7tD 445 <br /> ❑ .NONE (j 95.UNKNOWN ❑99.OTi1ER(Specify): 445' <br /> OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALAILMS 0 2.BALL FLOAT 0 3.FILL TUBE SHUT-OFF VALVE 452 <br /> ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V: PRODUCT./WASTVPIVING GONSTRUC iTON <br /> PIPING CONSTRUCTION ❑ SINCLE-WALLED 2.DOUBLE-WALLED ❑99.OTHEit 460 <br /> SYSTEM TYPE 1,PRt-tiSURE ❑2.CRAVfIY ❑ 3.CONVEN'IlONAI.SU(7CION ❑ 4,SAFE SUCTION 12)G(,R§263,6(.X3)1 4S8 <br /> PRIMARY CONTAINMENT Q 1,STFF,i. g4.FIBERQLASS 8.FLEXIBLL ❑ 10,RIGID PLASTIC 464 <br /> ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHERS !ify)„ _ 464° <br /> SECONDARY CONTAINMEmi, ❑ I.S-miu' r hIKEkLASS ❑ 8.FLEXIBLE ❑ 10,RIGID PI,ASTTC 464b <br /> ❑ 90.NONE ,... 15.UNKNOWN [] 99.OTi IrR(Slxcify): 464. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4f.44 <br /> V1::VENT;VAPOR: VERY(I!R)ANO 1dSER'J FILL PIPETIPING CONSTRUCTION. <br /> VENT L'KimARY CONTAINMENT ❑ 1.$TIiT(I. .FIBERGLASS U 10.RIGID MASTIC ❑ 90.NONIi [1 99.OTI IFR(Specify) 4643 <br /> 464e1 <br /> VENT SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.FIG]D PLASTIC 90.NONE Lj 99.al'HER(Spe.ify) 464r <br /> d601 <br /> VR PRIMARY CONTAINMENT 0 1.STEEL FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.(M IFP{Specify) 464, <br /> 464.1 <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 00.NONn L3 99.OTI EAR(Specify) 464h <br /> 464h <br /> VENT PIPING TRANSITION SUM P'CYpi; ❑ 1.SINOIAWALL2.DOUBLE WALL 0 90.NONE 4641 <br /> RISER PRIMARY CQNTAINMRNT Q 1,STFAJ. Er 4.FII3LRGLASS 0 10.RIGID PLAS'CI(' ❑ 90.NONE. ❑ 99.OTHER(Specify) 464] <br /> 464'1 <br /> R1SFR SECONDARY CONTAINMENT L.STEEL a PTBF..RGI,ASS ❑ I0.RIGID PI.ASTIC ❑90.1J9NE 99.OTHER(Spec fyj 464k <br /> 4641:1 <br /> FILL('OMPONI(NT$IN$TALI•RO I.SPIT.1,nU('Klil' ❑ 3.STRIKER I'LAIVBOT'l'OM PRO'IE(TOR ❑ 4.CONTAINMI'?NT SI)MP dStac <br /> VYY. JNDER:DIP NEER CO1W'i'AINNIENT:(LJDC} <br /> CONSTRUC TION TYPE ❑ 1.SINQLE WALL .DOUBLE;WALL ❑ 3.NO DISPF.N$ftRS II 90.N()Nr. 4693 <br /> CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS © 10.RIGID PLASTIC ❑ 99.OTHER S 'f) 4496-c <br /> v"I CO izOS10N pRdTECTIU <br /> $nai1.(:OMPONUtNTPROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4.IMPRISSF,I)CURRENT ❑ 6.ISOLATION <br /> IX;:.,APPLICANT SIGNATURE <br /> VERTIFICATION• I certify that t Ii'5T system b;compatible with the hatardops substance stored and that the Information provided herein is true,acct te. <br /> and in full cofappaucc with t 91 _ en <br /> APPLICANT SIGNATUR, DATE 47 <br /> 7 3j <br /> APPLICANT NAME(print) ,4471. APPLICANT TITLE <br /> Alin,r" Ila d d <br /> 11 <br /> ZiPCF UST-R-1/2 Rrv,(12/20071, ..,. <br /> ZZO/ E00•d SL90# 8Z:90 900Z/ZZ/LO <br />