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. s <br /> "'ViFZ= PROGRAM CONSOLIDATED FOP%4 <br /> .,9ib <br /> - UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (53 S paB <br /> T <br /> �.�r P•e•_er_ <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 6 AMENDED PERMIT X' 5 CHANGE OFINFOR.MATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (orarr.1y) a*d .L ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT S TANK REMOVED 439 <br /> BUSINESS NAIVE(s•r w FACILITY HAW-I o..a a.A•) FACILITY ID: ;L <br /> RQLo tk 3 6 ) <br /> LOCATION WITHIN SITE(op:.m 431 <br /> L TANK DESCRWnON (A soled plat plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK IDM J 432 TANK MANUF`ACTUnREVR 413 COWARTMFNTALIZED TANK Yes o .St <br /> D xvo2 Qs vY••:my..m yae bx ri mew ml. <br /> DA 1NST (YEAwm ) °3S TANK CAPACITY GALLONS s36 NUMBER OF COMPARTNZ5S .» <br /> ADDITIONAL DESCRIPTION(Fa Isei r m1y) U as <br /> IL TANK CONTENTS ' <br /> TANK USE '31PETROLEUM TY7E - . «9 <br /> I. MOTOR VEHICLE FUEL ❑la, REGULAR UNLEADED ❑2. LEADED CIS. JET FUEL <br /> (V mh.e rerylc.Pm.1...i>pl ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM e. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT OMMONNAME(e..St.a.•d•e•s3..+.0 l.w•ry P•a•1 u1 CASa(er w,.•am•mn....l•b.m..rvv•5 «2 <br /> ❑4. HAZARDOUS WASTE <br /> (�uw Oil) <br /> ❑95.UNKNOWN <br /> M. TANK CONSTRUCTION <br /> TYPE OF TANK I, SINGLEWALL L3 3. SINGLEWALLWITH L1 S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM .0 <br /> (Ly yryw,mh) EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 2, DOUBLE WALL ❑a. SIGNLE'NALL IN VAULT ❑99. OTHER <br /> I TANK MATERIAL-ywn . BARE <br /> STEEL FIBERGLASS%PIAS'C i. CONCRETE <br /> 93. UNKNOWN «• <br /> lyra w..r wlyl <br /> 02. STAINLESS STEEL 06. STEEL CLAD WTIBERGLASS [3 9. FRP COMPTIBLE W/107.METHANOL W.OTHER <br /> REINFORCE)PLASTIC(FRP) <br /> I TANK MATERIAL-d•ryu.t 1. BARE STEEL FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN US <br /> (o.a r.r whl <br /> 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑r. FRPCOMPTIBLEW/100%METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) Cl 10.COATED STEEL <br /> ❑S. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED0 3.EPDXY LINING Ll S.GLASS LINING U 95.UNKNOWN «6 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑6 PHENOLIC LINING 6ZNNLINFD ❑99 OTHER <br /> (Qck waYr mlyl (Fc bol care wlyl <br /> «e DATE INSTALLED <br /> OTHER CORROSION ❑ I MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC C1 UNKNOWN <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> (Ckeck we iem mlYl ❑2 SACRIFICIAL ANODE (For boli...miy7 <br /> SPILL AND OVERFILL YEAR INSTALLED 439 TYPE(1wl.mmlyl III OVERFILL PROTECTION EQUIPMENT'.YFAR INSTALLED 452 <br /> (ores•1l aw qph) (SPILL CONTAINMENT 0 ALARM ❑]FILL TUBE SHUTOFF VALVE <br /> 2 DROP TUBE ❑2 BALL FLOAT ❑a EXEMPT <br /> 3 STRIKER PLATE <br /> [V.TANK LEAK DETECTION to anaq•b.•tu•.....w.e P•.eI..I r.n k ms...r mwe l.ul.aw=y.5 <br /> IF SINGLE WALL TANK ICbat.n m..PPhI 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (oat r:r mlPl <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTGN ❑ (VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG C37 GROUNDWATER ❑ NUAL MONITORING <br /> ❑6 STATISTICAL INVENTORY RECONCILIATION ❑r TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO%DAY) ... ESTIMATED QUANTITY OF SUBSTANCE REMAINING X56 TANK FILLED WITH INERT MATERIAL? 157 <br /> gallons ❑ Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly S W RCB Form B <br />