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r� <br /> v. <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> oq <br /> LL UNDERGROUND STORAGE TANKS-TANK PAGE 1 c+ <br /> _ � 15 b (fv+o pages per lank) -��� <br /> Page _ Of <br /> TYPE OF ACTION D1.NEWSITEPERMIT D 4. AMENDED PERMIT D 5. CHANGE OF INFORMATION) D 5.TEMPORARY SITE CLOSURE �fln 4�• <br /> (CheckeM Mm ortly) D 7. PERMANENTLY CLOSED ON SITE N F" <br /> 113.RENEWAL PERMIT (Spsdly lseepn-brbulues oMy) (Speary Merge.brloulux pnlp D S. TANK REMOVED 430 <br /> BUSINESS NAME(Sema u F(ICI�ITY,NAME a DBA-Domg S.i M) FACILITY 10 N 1 <br /> �uJJ QT f <br /> I L <br /> LOCATION WITHIN SITE MPOM 9 431 <br /> I L I I � Tri " <br /> L TANK DESCRIPTION <br /> TANKID9 TANKMANUFACTURER COMPARTMENTALIZED TANK 11 Yes Na <br /> II'Yef,complete one papa br.s ranp.n,,.m <br /> DATE INSTALLED(YEARRMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For1aW um eNk9 <br /> B.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑te. REGULAR UNLEADED ❑ 2 DED D 5. JET FUEL <br /> fff a ,,compote PoOm mTyW) 0 l PREMIUM UNLEADED DIESEL 11 B. AVIATION FUEL <br /> D 2. NON-FUEL PETROLEUM 1c MIDGRADEUNLEADED D 4, GASOHOL 1189. OTHER <br /> D 3.CHEMICAL PRODUCT CAS Y M..HMIANPYa 04 re 1.M.ffl ryppe) <br /> ❑ 4. MzARDOUS WASTE pmdvesa COMMON NAME(hom HI Manchu Maremle M.tm Pepe) <br /> UaeOOi9 <br /> 95 <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 11 1 SINGLE WALL 11 3. SINGLE WALL WITH 11 �5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check.MmOmy) 11 2. DOUBLEWALL EXTERIOR MEMBRANE LINER 045 UNKNOWTI <br /> D 4, SINGLE WALL IN A VAULT [199. OTHER rT"�"1 <br /> TANK MATERIAL-ptlmary W,* 11 1 BARE STEEL 11 3, FIBERGLASS I PLASTIC 05 CONCRETE y+im uNKNOWN <br /> (CMcka "rc .My) D 2, STAINLESS STEEL 04 STEELCIADWIFIBERGIASS 11 e. FRP COMPATIBLE W11M%METHANOL D99 OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-ee mq tank 11 1 BARE STEEL D 3. FIBERGLASS I PLASTIC 08, FRP COMPATIBLE WItOD%METHANOL Crz. UNKNOWN <br /> (CMtl om dem orllyf 11 2- STAINLESS STEEL 11 4 STEEL CLAD WIFIBERGLASS D 9. FRP NON-CORRODIBLE JACKET 1199. OTHER <br /> REINFORCED PLASTIC FRP) D10 COATEDSTEEL <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LINING 11 1. RUBBER LINED 11 3. EPDXY UNING 11 5, GLASS LINING .' UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ I. PHENOLIC UNING ❑ 6. UNLINED 099. OTHER (FOrlocel uas oMy) <br /> CMck oM 4am o <br /> OTHER CORROSION 11 1. MANUFACTURED CATHODIC ❑ 3. FlBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT [3 N. OTHER (FOrbcel vae OrdN <br /> (CMck olMirem only9 ❑ 2. GACRIFICIAL ANODE <br /> SPILL AND OVERFlLL YEAR INSTALLED TYPE(FOrk uas Phry) OVERFILL PROTECTION EQUIPMENT r YEAR INSTALLED <br /> (CIwk"fwapply) ❑ 1. SPILL CONTAINMENT 11 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> - IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CMM a#Oats IF DOUBLE WALL TANK OR TANK WITH BLADDER Check oMirem <br /> D 1• VISUAL(EXPOSED PORTION ONLY) 11 5, MANUAL TANK GAUGING(MTG) D 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> D 2. AUTOMATIC TANK GAUGING(ATG) 11 S. VADOSEZONE D 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 11 3. CONTINUOUSATG D T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 11 4. STATISTICALINVENTORY RECONCILIATION(SIR)♦ ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING N. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMODAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLEDWTTH INERT MATERIAL? <br /> y&Ions D Yea 11 NO <br /> CUPAFORM(4199) / Formerly SVVRC8 Form B <br />