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UNInED PROGRAM COMOLEDATED FORM <br /> UN I DERGROU"STORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (O-eforraperUMI <br /> TYPE OF AC77ON (cksck one 7."dn�K Aor a USTclasure or removal.complete o4 thissection and Sections 1.If MI.IV.and IX bek-) <br /> 1.NEW PERMIT 1.RENEWAL PERMIT S.CHANGE OF INFORMATION <br /> S.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON S(TE. 0 8.UST REMOVAL 43A <br /> DATE U$T PERMANENTLY CLOSED: fDATE EXISTING UST DISCOVERED: 1.7 ot 1- 2011 <br /> :L:FACHM 1NFORT"TION <br /> FACILITY LD#(Agatcy trie Only) <br /> BUSINESS NANE(Same as racifiv Name or DBA-DoMg Boiness As) 3. <br /> i"01t_ 1-2-SC2 EWI_t" <br /> BUSINESS SITE ADDRESS 1w. CITY <br /> 7-1 Wvt <br /> TA..jWDE9C <br /> TANKID# 412- TANK MANUFACTURER 433. TANKCONFIGURATION:THIS TANK IS 434, <br /> ffI.ASTAND-ALONETANK compIdtonparfarmh <br /> E3 2,0NEWAMCARrAmmuNg ��iatwwdL <br /> -ErAT­EUTf,SySTE 410- NUMBER OF COMPARTMENU IN THE UWr 437. <br /> ,M R�WALLED 435. TANK MANN IN UALEGNs <br /> k <br /> 111 TANK USE AND CONTENTS <br /> wwas-E a MOMIt VEHIC[I M_ 0 lb.,MAPJNA FUELING 0 lc.AVtATiON FUMING <br /> 13- <br /> C)3,CHMCAL PRODUCT STORAGE E3 4.HAZARDOUS WASTEOndadei U50 011) 13 5.E&MGENCYGENtMT0RFUEL(HSCj2 31.5(dj <br /> 13 6.OTHER GENERATOR FUEL R'95.UNKNOWN 0 99.OTHER.OrAdify): <br /> CONTENTS iiijbLEUM. E) <br /> Ia.REGUIAR UNLEADED a Ia.MIDGRADRUNLEWED Cj:jb.PRE1%4UMUNLEADED <br /> 0 3.DIESEL 0 1JETRAL E3 6.AVIATION GAS <br /> 13&tE'MOLEUM BLE40 FUEL _I-_0THCRPMRO M@ff_djX_4"fMi- <br /> N­, LFUM:Q 7.USED OIL E3 METHMNOL 440h <br /> 11.OTHER NON-PETROLEUM(SPNOW: krim., tvw-VIL - <br /> W. TANK CONSTUCTION <br /> 443. <br /> TYPE OF TANK jrLSINGLEWALL C3 1 DOUBLE WALL 13 9S.UNMOWN <br /> PRIMARY CONTAINMENT (3 1.STEEL [3 3.FIBERGLASS 0 6ANTERNALBLADDER <br /> n 7 STEEL+INTERNAL LMG LE3 95.UNkNOWN t&90"OT1iFA(SPeC1 443, <br /> SECONDARY CONTAINMENT 13 LSTEM 0 3.Fismaws (3 6.EXTERIOP MENMRANF UNER C1 7.JACKETED 4454. <br /> R90.14014E 0$.UWWOWN 0 99.OTHIR'(Smify, <br /> OVERFILL P N (3 1.AUDIBLF&V.ISUALALARMS (3 2.*BALLFLOXT E3 3.FILL TUBE SHUT-OFF VALVE 451 <br /> C3 4.TANKMEETS REQUIREMENTS FOR EXEMYFION FROM O.VEWLL PREVENTION EWIPMENT <br /> V. -PRODUCT WA$17 PITINO CONSTRUCTION <br /> PIPING CONSTRUCTION 0 I.SINGLEWA <br /> LL-0_2._D0UE;L9WALL OTHER <br /> f]3.CONVWWN4tSUCTI0N a 4.SAFE g=gN,23 OCEL126AjX311 45& <br /> SYSTEM YPE J.PRESSURE _q I.GRAVITY <br /> PRIMARY CONTAINMENT 13 I'STEEL E3 4.iwEi5i_" C3 �,n LE 13 Ia RIGID PLASTIC 464a. q64. <br /> Q 05.UNKNOWN j5 ;,0THER acify): <br /> L02- 464k <br /> SECONDARY NTXiNMENT (3 1.STEEL E3 4.FIBERGLASS 13&FLEXIBLE (3 apdaiDPLAsTic <br /> NONE Q 95.UNKNOWN' 99.OTHER(StiecHY); 4W <br /> (390. 4M& <br /> 4IPINGfrU INS CONTALNMEWT-SUMP TYPE Q I 2w D0TJ=WALL 0 90,NONE <br /> -CO CTION <br /> W.L VE APOR RECOVERY(VR)AND RISER I FILL PIPE PIPING 9 NSTRU <br /> 464-- <br /> 1VENT PRIMARY CONTAINMENT ffirl.STEEL (3 4.LFIBEPOLASS 0 Jo'R[aH)P'LASTIC 0 Oo.NONE C3 M OTHER(Spocify): _iw <br /> VENT SECONDARY CONTAINMENT E3 1.99TEEL E3 4.FIBERGLASS E3 11 RIGID PLASTIC 13 90,NONE t3 99-OTHER(*d(ft <br /> VR PRIMARY CONTAINMENT §tf.STEEL 6 4,FIHEiGL�A C3 10-RIGMPLASTIC 13 9M NONE E3 99-UMERICS�_ry): <br /> Vk SECONDARY CONTAINMENT E3 LSTERL 0 4.FtBERG(ASS [3 to.PiGID PLASTIC E3 90.NONE E3 9,9.OTHER(Sp=ifY): <br /> VENT pipING TRANSITION S.UMP TYPE 0 1.SINGLE,WALL Q 2.DOUBLE WALL OLKNONE THER Specify) <br /> .RISER PRIMARY CONTAINMENT A i�STEEL_0 4-PMERGLASS 13 10-04PMPLAS-nc E3 90.NONE 0 99-0 <br /> 4ANG S 13 9 OTHERISPeafy <br /> RISER SECONDARY CONTAINMENT E3 LSTEEL 0 4-EMERGLASS 0 JO.PMIDPLASTiC 13 N 9- 1 <br /> .FJLLCOMPONENTS INSTALLED I.SPILL DUCKET Q 3.STRIKERPLATMTTOM PROTECMR 13 4.cottrAINMENT SUM <br /> VU 'UND 'D <br /> ISOF <br /> ulk 'N:"L <br /> TIONTYPE I.SINGLEWALL __ w 2 DOUBLE WALL 13 3.NO DISPENSERS 0 90.NONE 409L <br /> CONSTRUCTION MATERIAL 1.STEEL E3 4.FIBERGLASS d jo.RIGID pEAsTic IA 99.OMER(Specify) (ONLOLM-i"g- <br /> VM <br /> �CORROSION PROTECTION <br /> MTgL QqL4p0NENT PROTECTION 0 1 SACRtFiCIALA"ELSI 13 4�IMPRESSED CURRE 9 NT 13 6 WOLATWW 449. <br /> APPLICANT 4ATURE w <br /> RTIFjCATjj)_7N_I Certify that this UST system Is compatible wJtk the bawrdous sulatance stored and that the information provided herein IS trIJ4 <br /> �aceurato_aa*�iLufi compliance vwvttthi I requirements. <br /> 470. <br /> APPLICANT SIGNATURE DATE of_+, Zotk <br /> APPLICANT N 471. APPLICANT TITLE 4r-. <br /> UPCF UST-U Rev.(12/2007)-III www�uaido".org <br />