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• L UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UST Tank-2 <br /> Page 2 a 8 <br /> IV EjEwGJHM0MATInM <br /> A PIPING TYPE ❑1 ABOVEGROUND ❑1 SUCTION ❑2 PRESSURE ❑3 GRAVITY ❑99 OTHER <br /> Check all that apply ®ti. ❑1 SUCTION ®2 PRESSURE ❑3 GRAVITY ❑99 OTHER 448 <br /> UNDERGROUND <br /> B.CONSTRUCTION ❑i.ABOVEGROUND ❑1 SINGLE WALL ❑2 DOUBLE WALL ❑3 LINED TRENCH ❑95 UNKNOWN ❑99 OTHER <br /> Check all that apply ®ii. ®i SINGLE WALL ❑2 DOUBLE WALL ®3 LINED TRENCH ❑95 UNKNOWN ❑99 OTHER <br /> UNDERGROUND 449 <br /> C.MATERIAL AND ❑i ABOVEGROUND ❑1 BARE STEEL ❑4 FIBERGLASS PIPE ❑8100%METHANOL COMPATIBLE WRAP ❑11 FLEXIBLE PIPING <br /> CORROSION <br /> PROTECTION El2 STAINLESS ❑5ALUMINUM ❑9 GALVANIZED STEEL ❑95 UNKNOWN <br /> STEEL ❑6CONCRETE ❑10 CATHODIC PROTECTION ❑99 OTHER <br /> ❑3 PVC ❑7 STEEL W/COATING <br /> ® <br /> it ❑i BARE STEEL ®4 FIBERGLASS PIPE ❑8100%METHANOL COMPATIBLE WRAP ❑11 FLEXIBLE PIPING <br /> UNDERGROUND ❑2 STAINLESS ❑5ALUMINUM ❑9 GALVANIZED STEEL ❑95 UNKNOWN <br /> Check all that apply STEEL ❑6CONCRETE ®10 CATHODIC PROTECTION F1 99 OTHER <br /> ❑3 PVC ❑7 STEEL W/COATING 450 <br /> D.LEAK DETECTION ❑1 MECHANICAL LINE LEAK DETECTOR ®3 CONTINUOUS INTERSTITIAL ED <br /> 5 AUTOMATIC PUMP SHUTDOWN FOR LEAK DETECTION 8 <br /> Check all that apply MONITORING SYSTEM DISCONNECTION 8 MALFUNCTION <br /> ®2 LINE TIGHTNESS TESTING ❑99 OTHER 450 <br /> ®4 ELECTRONIC LINE LEAK DETECTOR <br /> UST TANK �I <br /> ❑1 VISUAL CHECK ®4 AUTOMATIC TANK ®7 CONTINUOUS INTERSTITIAL MONITORING ❑10 MONTHLY ❑95 UNKNOWN <br /> GAUGING(ATG) TANK <br /> TESTING <br /> CSLD set at <br /> 99% <br /> 92 MANUAL INVENTORY 1:15 GROUNDWATER MONITORING ❑B SIR 1911 CONTINUOUS ❑99 OTHER 451 <br /> RECONCILIATION ATG <br /> ❑3 VADOSE MONITORING ❑6 ANNUAL TANK TESTING ❑9 WEEKLY MANUAL TANK GAUGING ❑91 NONE <br /> VI.TANK CLOSURE INFORMATION(permanent closure in place) <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF WAS TANK FILLED WITH INERT E] YES <br /> ❑ NO <br /> 452 SUBSTANCE REMAINING gal. MATERIAL? <br /> 453 454 <br /> VI.APPLICANT SIGNATURE <br /> I certify Mat the information praiide4 herein is true&accurate to the best of my knowledge. OWNER/OPERATOR TITLE 457 DATE 458 <br /> DINNER/OPERATOR NAME(pnnted and signed) 456 <br /> Diane Leri Retail ESH 08113199 <br /> Penna Approved by Permit Expiration Date <br /> 2 <br /> Formerly SWRCB Forth B <br /> `/ \.001 <br />