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UTPfFIED PROGRAM CONSOLIDATED FORK- <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 G/ / <br /> /. ;' ��/�✓�� (fwoP rank) <br /> (,_,/ Paga _ of <br /> TYPE OF ACTION 01.NEW SITE PERMIT Cl 4. AMENDED PERMIT \A 5. CHANGjE'OFINFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Lkxkom dem way) �a !ewl4 t•��2�i�L� ❑ L PERMANENTLY CLOSED ON SITE <br /> ❑1RENEWAL PERMIT (Speclly naaon. &w wvas orNY) (Spealy ca -forlocal use only) 0 8. TANK REMOVED 430 <br /> BUSINESS NAME ISMS as FACILITY NAME or DBA-Dokq Busine s As) FACILITY ID N t <br /> a-��,)wysf <br /> LOCATI WITHIN SITE Potons9 /]i <br /> � as3 'Cc <br /> 1.TANK DESCRIPTION <br /> TANK ION O TANK MANUFACTURER /y COMPARTMENTALIZED TANK 0 Yea 0 No <br /> / (/) _ If'Yes',complete one Pape for eanin compartment. <br /> DATE INSTALLED(Y MAO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ©O <br /> ADDITIONAL DESCRIPTION ff wnoal use 0*) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 0 L. REGULAR UNLEADED ❑ 2. LEADED 0 5. JET FUEL <br /> (Nmukao.compawt,Patn4a mTyps) 1D. PREMIUM UNLEADED 0 3. DIESEL �❑/B. AVIATIONFUEL <br /> 0 2, NON,FUELPETROLEUM tc. MIDGRADEUNLEADED 0 4. GASOHOL J�V, <br /> . OTHER <br /> D 3. CHEMICAL PRODUCT CAS N(hqm Nanrdom MMeAala In page) <br /> COMMON NAME(Som Wurtlow Mafedeh Inronforygge) <br /> ❑ 4. HAZARDOUS WASTE(Intluda <br /> UasA ON) <br /> A9 UNKNQZN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1, SINGLE WALL 0 3, SINGLE WALL WITH 0 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Gho onademon/y) D 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> D 4. SINGLE WALL IN A VAULT D 99 OTHER <br /> TANK MATERIAL.pnmary Wyk 1, BARE STEEL 0 3, FIBERGLASS/PLASTIC 0 5, CONCRETE 095. UNKNOWN <br /> (Chock wn dem o*j 0 2. STAINLESS STEEL A. STEEL CLAD W(FIBERGIASS 0 8, FRP COMPATIBLE Wll0 METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL secondM'tank 0 1 BARE STEEL 0 3. FIBERGLASS/PLASTIC 0 8, FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (OMckoneifnn.nly) 0 2. STAINLESS STEEL 0 4 STEEL <br /> CC OWPLABTICGFRP) 0 B. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED <br /> ❑10. COATED STEEL <br /> 0 S. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> ORCOATING ❑ 1. RUBBER LINED ❑ 3. EPo%Y LINING ❑ 5. GLASS LINING ❑B5. UNNNOVJNg3 <br /> ❑ 2. ALKYD LINING 0 4. PHENOLIC LINING ❑ B. UNLINED D99. OTHER Fczlocslvae <br /> hock qm Mm ) DATE INSTALLED <br /> OTNER CORROSION D 1 MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION A 0 <br /> ❑ 4. IMPRESSED CURRENT � OTHER (Fwbwluas oNy) <br /> (CAack orre iNm oMy) 0 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use Only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED V q <br /> (Chock no net apply) D 1, SPILL CONTAINMENT �01 M 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE FLOAT ❑ 4. EXEMPT <br /> 0 3. STRIKERPLATE <br /> - IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK fCtwck OMI a <br /> IF DOUBLE WALL TANK OR TANK WITH BUDDER Chock ono Nem o <br /> 01. VISUAL(EXPOSED PORTION ONLY) MVAWSE <br /> K GAUGING 01. VISUAL WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG( NE 0 2. CONTINUOUSINTERSTITIAL MONITORING <br /> 3. CONTINUGUSATG TER 0 3. MANUAL MONITORING <br /> 4. STATISTICAL INVENTORY RECONCWATION(SIR)• NG q.-�_BIENNIAL TANK TESTNG ��I, "�� <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YR/MO/DAY) ESN'-Mme�TED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIALT <br /> s-Y ( - DO _IT(JCJ geNona 101 Yes No q wry, <br /> a- -O o <br /> CUPAFORM(4/99) ForMrly SWRCB Form B <br /> Gj�Z/�(/V <br /> �/ ✓ �%MO <br />