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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (no pages pa fang <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ a. AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) <br /> 21;6. TEM ITECLCSURE <br /> (CAeok Dna Xam Doty) PERAUNENTLY CLOSE)ON SITE <br /> ❑3.RENEWAL PERMIT (Spaifymaon-bxbcaluu only) (Sp«+ry cAarga-brbcN ms Dray) ❑ B. TANK REMOVED An <br /> K <br /> ME(Same a FACILITY NAME w 0BA-DoingewireMAa) FACILITY ID Y <br /> TIiIN SITE(OpaorMg 431 <br /> L TANK DESCRIPTION <br /> TANK 10 TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yas No <br /> (Q ,.�(� s. ♦�� II'Van',mmgNe we page fw-aKA wmpamnanl. <br /> DATE INSTALLED(YEARRAO) TANK CAPACITY IN VGAVLLOEN3'^-a CR✓ NUMBER OF COMPARTMENT$ <br /> ADDITIONAL DESCRIPTION(F KkXPI uaa 1-Y) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> CT1. MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑,22LLEADED ❑ 5. JET FUEL <br /> (Ilmae,eE,PwlPMfa PafmMum TYpa) 1B. PREMIUM UNLEADED 1�]. DIESEL ❑ a- AVIATIONFUEL <br /> ❑ 2. NON-FUELPETROLEUM �lc MIDGRA,E UNLEADED ❑ 1. GASOHOL 099. OTHER <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(I/om NaxaNOw MaNrials lnranfarypage) CAB Y@om Hazwfous Mstwala:nvenfary page) <br /> 0 4. HAZARDOVSWASTEf0XVlas <br /> U4aa O9) <br /> III.TANK CONSTRUCTION <br /> Fd...1my <br /> 1. SINGLE WALL 0 3 SINGLE WALLWTH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> .1my 0 2. COUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ,0 4. SINGLE WALL IN A VAULT 09q, OTHER <br /> AL-primary tank 1. BARE STEEL ❑ 3. FIBERGLASS/FUSTIC ❑ 5 CONCRETE ❑95 UnKNOVM <br /> oMy) 02. STAINLESS STEEL 04. STEEL CLAD W/FISERGLASS O e FRP COMPATIBLE W/1W%METHANOL 099. OTHERREINFORCED PLASTIC(FRP) <br /> AL-saconaary Wk 1 BARE STEEL 0 3. FIBERGLASSIPLASTIC 0 a FRP COMPATIBLE W/100%METHANOL UNKNOWN(CAecomPMy) 0 2. STAINLESS STEEL 0 4, STEEL CLAD WIFISERGI.ASS 0 9. FRP NONCORROOIBLE JACKET ❑99. OT-IER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING DATE INSTALLED <br /> OR COATING 0 1. RUBBER LINED 4 3 EPDXY LINING ❑ 5. GLASS LINING 85. UNKNOWN433 <br /> 0 2, ALKYD LINING 0 4. PHENOLIC LINING ❑ B. UNLINED ❑99. OTHER (ForlooalwsoM <br /> k.Xam ) DATE INSTALLED <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOPM 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER (FO(lwluaa aMy) <br /> (C kone l}km only) 0 2. EACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwloca/use Dory) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED ♦♦♦♦♦♦ <br /> (Q'llaCkdMet apply) 0 1 PILL CONTAINMENT 0 1. ALARM � 0 3. FILL TUBESH OF�VE <br /> D <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT__ ❑ 4. EXEMPT <br /> 0 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> IF SINGLE WALLTANK aY prala IF DOUBLE WALL TANK OR TANK WITH BLADDER CAeck ane iNm onl <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) f ❑ S. MANVALTANK GAUGING(MTG) // 0 1, VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK WUGING(ATG)- N///y/^Ilr' ❑ 8. VADOSE ZONE FFFFFr'''� / ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROVNONATER I / ❑ ]. MANUAL MONITORING <br /> ❑A. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING ❑q9, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YNMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING a35 1 TANK FILLED WITH INERT MATERIAL' <br /> gtllons 0 Y Na <br /> Formerly SVVRCB Form 8 <br /> CUPAFORM(4199) <br />