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fit- <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK{ <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) Q <br /> TYPE OF ACTION (Check one item only, Foran USF perma]>En;closure or removal,complete only this secti and Sections 1,11,111,IV,and I X below) 430 <br /> ❑ 1.NEW PERMITIg 3,RFNF,WAT.PERMIT 5.CHANGE OF INFORMATION <br /> TEMPORARY6. UST CLOSURE. Z UST PERMANENT CT.0,SURF.ON SMUS1 DISCOVERED: AL ((JJ <br /> RM: <br /> .. DIS 430b <br /> -MAI,Y CI.OSF..D: DATE EXISTINGS <br /> U'1 Rh <br /> DATE.UST PL'KNENT, <br /> L::,;FA�L'LLITY.INFQ ATI(1�€..... . <br /> PACILrry Ill#(Agency Use(Jnly) <br /> '1 <br /> BUSMESS NAMEAqavne al FACILITY NAME or DBA-DoBusiness As)�E )c, / rr{ <br /> / ! <br /> BUS .S CITY <br /> / 1 <br /> Sos /`p 1� / loa <br /> IK TANK UFSGXP i 1N':. <br /> TANK ID# 43; TANK MANUFAC'i'�E c 433 TANK CANFIOURATiON: THIS TANK IS 4:34 <br /> L/� 1.A STAND-A].ONETANK <br /> 0?ZAtumENrED UNIT. <br /> DATE UST SYS EM INSTALLED 455 TANK CAPACITY IN GAI.I.ONS 436NiLI"lR OF COMPAKTMENTS IN THE UNIT 437 <br /> - - <br /> - <br /> Z. <br /> TA FTS%:-kND.CON7N;1`S` <br /> TANK USF.. Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FEELING ❑ ic.AVIATION FUELING 439 <br /> © 3(714EM1CAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Indudee Used Oil) ❑ S.EMERGENCY GENrRATOR FI;FL IRS(:�252il2.5(c)) <br /> ❑ 6.0'rma GENERATOR m)r1. ❑ 95.t ❑ 99.OTHER(Specify): 439' <br /> CONTENTS PETROLEUM: ❑ 1.Rr(iu1.AR 17NLEADE lc.M1tXiRAU£UNLEADED• ❑ lb.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 6.AVIATION CTAS <br /> ❑ R,PMOL•EUM$I;FNP FUrI: Q 9,OTurR PECRULrL;m $ 'fy)• 4403 <br /> NON-PETROLEUM:❑ 1.USED OIL ❑ 10.ETHANOL <br /> ❑ I I.cyrHER NON-I'lrl-ROLEUM S 'f . 4406 <br /> ..: fV: TRK CQST�t[bCP10N;; <br /> TYPE OF TANK ❑ 1.SINGLE WALL DOUBLE WALL U 95,UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL Ln.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> [] 7,STF,.FI:4 INTERNAL LINING; ❑ 95.UNKNOWN 0 99.071IrR (Specify)- _rye. 444„ <br /> SECONDARY CONTAINMENT ❑ 1.STEELF1BLRCLASS [I 6.EXTERIOR MEMBRA.NL LINER ElT JACr7 <br /> KrD 445 <br /> ❑ 90.NQNr 095.UNKNOWN ❑99.OTHER(Specify): 445$, <br /> OVERFILL PREVENTION ❑1.AUDIBLE-A VISUAL ALARMS ❑ 2.BALL FLOAT ❑ S.FILL TUBE SkUT-OFF VALVE 452. <br /> ❑4.TANK M1;ITTS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVEN'T'ION E()111PMENT <br /> V. 'PRODUCT'}'WASTE•PTPING.CONST'RUCTIUN <br /> NNNG CONSTl2UCl'ION 1.NINULF-WAI.LL'U <br /> X1.0 <br /> .DOUBLE-WaLLED El".OTHER 460 <br /> SYSTEM TYPE I.PRF:1SURr ❑ 2GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR,12636(3)(3)1 458 <br /> PRIMARY(:UNrAINmr.NT ❑ I.STEEL �'4.F11311R()I.ASS ❑ 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464 <br /> [�90.NONE. ❑ 95.UNKNOWN [1 99.OTHER(Specily): <br /> _ 4643 <br /> SECONDARY CONTATNMENT ❑ 1.STEEL kr 4,FIBFROLASS ❑ S.FLEXTI3I.17. ❑ 10.RIGID Pt„ASTIC V 4646 <br /> ❑ 90.NONE C) 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPING/TURBINE CONTAINMENT SUMI''I'YPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464,1 <br /> . :.:S!T:'��N'I",VA P.t3tt keit~CQ'V'E�'Y' AND,RISER/FILL:PII'F PIPIAFG CONSTIrUCTIQN. <br /> VENT PRIMARY CONTAINMENT ❑ 1.STl•.rl. 4.FIn1iRG1.ASS 0 10.RIGID I'LA.LI'IC: ❑ 90.NONE ❑ 99.an Elm(Specify) 4643 <br /> 464G] <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS Q 10.RIGID PLASTIC 90.NONE �.O'fxEx(Specify) 64h <br /> 44<A <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL 9,4.FIBERGLASS ❑'10.RI(,11D PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E <br /> 464}1 <br /> VR SECONDARY C0%7ATNMEN•T ❑ 1.STEM, W 4.FInrRGi.AS3 ❑ 10.RIGID PLASTIC: ❑ 90.NONr ❑ 99.(ITT IL"R(Specify) 464h <br /> 464111 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL. 2.DOUBLE WAIJ. 9U,NONr. 4641 <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464] <br /> 464'2 <br /> RISER SECONDARY MNTAINMF.Nf 1,STF.E1. 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILE.COMPONENTS INSTALLED ❑ 1.SPILL BUCKUT ❑ 3.SiRIKlilt PLATEMOTTOM PROrE("TOR 0 4.CONTAINwmrsIIMP 4813.; <br /> ''VU.JTNT)FR;DiSPE3 ERC ,NTA11YMENT:EIJ'DQ <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL JZ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE <br /> CONSTRUCTION MATERIAL .�.E3 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c <br /> 77- <br /> .... <br /> V'k11: CO-M #ON.PRO`ECTlON <br /> STEEL(:OMPONL•NTPROTTC:TION ❑ 2SAC,:RIFMIAI_ANODE(S) ❑ 4.IMPRESSEDCURREN'f ❑ 6.ISOLN11ON <br /> Ilk. APPLICANT SIGNATURE <br /> CMtT1F1CATION, i certify tis system is compatibtt with the hAr9rdons subrtanee Slored and that the inrurmktion provided beeelo L%trueA40iratt, <br /> And in Tint 1' With 91 uirements_ <br /> APPT,TCANT STGNATLTRF DATE v alo. <br /> 1 a <br /> APPLICANT NAME(priiit) ) APPLICANT TITLE <br /> UPCF UST-B-11Z xev.(7212(#11ya.J <br /> TTO/ t00'd SL90# 6Z:90 900Z/ZZ/LO <br />