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"NIF'IED PROGRAM CONSO ATED FOPX14 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TA 4tl <br /> { \ <br /> 0-0 pages tankV <br /> hr <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT )w 5 CHANGE OF INFORMATION [36 TEMPORARY SITE CLOSURE <br /> f@aa�.ka4Wr) .s pdat7- ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWALPFRMIT (Spmfy Mm -r°.kolm mly) I TANK REMOVED 430 <br /> BUSINESS NAME(s a FACMXrY MAW ROeA-u°'I@iMMM) 3 FACILITYID: >•:y° <br /> t�Qto 47 (, o 5 <br /> LOCATION WITHIN SITE(op:-'l n1 <br /> L TANK DESCRIPTION (A soled plot plan with the location of the UST rystcm including buildings and lmdmarks shall be submitted to the local agency.) <br /> TANK ID K a TANK MANUFACTURER a3 COMiPARTMENTALIZED TANK Ya o 434 <br /> 1*5 'j\q� �(21QJCQ� VCzo �w m.Wee"ma aim.. <br /> DATE INST (yEAR/MO) 435 TANK CAPACITY IN GALLONS 4J6 NUMBER OF COMPART S 437 <br /> C) b0 <br /> ADDITIONAL DESCRIPTION(Fabalm WY) ns <br /> D-TANK CONTENTS ' <br /> TANK USE43 <br /> 9 <br /> P OLEUM TY?E - 449 <br /> I. MOTOR VEHICLE FUEL I• REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL <br /> Iva.htl m.ol..e Mm.I..a Tm) PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL D 99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME(am tlu..d.n M..i.l.i.warypWl MM CAS)I(am(4•n.4w.Mnm.l.levm.ary Wa4) MZ <br /> [14. HAZARDOUS WASTE <br /> (I.rY.dm u.•a an <br /> ❑95.UNKNOWN <br /> M. TANK CONSTRUCTION <br /> TYPEOFTANK I. SINGLE WALL Ej 3. SINGLE WALL WITH Ll J. SINGLE WALL WITH INTERNAL BLADDER SYSTEM u3 <br /> (Cs km.:m mhl EXTERIOR MEMBRANE LINER '095. UNKNOWN <br /> 2. DOUBLE WALL ❑4. SIGM:'WALL M VAULT Cl 99. OTHER <br /> ! TANK MATERIAL- u . BARE STEEL FIBERGLASS/PLLiTC Ll i. CONCREIi 0 95. UNKNOWN 44. <br /> mly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑a. FRP COM4PTIBLE W/100•/.METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(ILP) <br /> I TANK MATERUL-.m.4.p l..k 1. BARE STEEL FIBERGtASSl PLASTIC 5. CONCRETE 95. UNKNOWN w3 <br /> (@,y,••�•�sry) <br /> 02. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGUSS ❑S. FRP COMPTIBLE W/100%MEFHANOL ❑99.OTHER <br /> I REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING I.RUBBER LINED 3.EPDXY LINING �,�5.CUSS LINING 95.UNKNOWN w6 DATEINSTALLED M7 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING &O NLTNFO ❑99 OTHER <br /> mly) (Far l.al m mly) <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC 3 FIBERGLASS P,EMEORCED PLASTIC ..e DATE MSTnLLED <br /> ❑95 UNKNOWTJ <br /> PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT Cl 99 OTHER <br /> (Cksk me:W.mry) ❑2 SACRIFICIAL ANODE (F..k I.. .10 <br /> SPILL AND OVER ILL YEARINSTALLED 430 TYPE(l i..mly) 431 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 4R <br /> (@ak.lhkn apryl I SPILL CONTAINMENT ❑I ALARM ❑JFILL TUBE SHUT OFF VALVE <br /> 2 DROP TUBE ❑'- BALL FLOAT ❑4 EXEMPT <br /> 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A e..ep.m.r U..m...a,e w•e•.•a.n x abd:Ir °u.i.cl.amcy.l <br /> IF SINGLE WALL TANK(Cb k•ll lko spry) 433 IF DOUBLE WALL TANK OR TANK WITH BLADDER X34 <br /> (@xk.k-mlyl <br /> ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTGN ❑ I VISUAL(SINGLE WALL M VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑J CONTINUOUS ATG ❑7 GROUNDWATER ❑ 44ANUALMONTTORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑I TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING C1 99 OTHER <br /> IV.TANK CLOSURE INFORMIATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YMO(DAY) 433 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 416 TANK FILLED WITH INERT MATERIAL? 431 <br /> RJ <br /> gallons ❑ Ya ❑ No <br /> UPCF(12/99 revised) 10 Formerly S W RCB Form B <br />