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UNIFIED PROGRAM COOK SOLIDATED FORM pYTANKCLO p�U"ERGROUND STORAGE TSS - TANK PAGE mak)of. . L`.FOR?SATIO,1 ❑ 6.TEMPOecho.TYPEOF ACTION .YEW PEPUN I Q ❑ 7.PERMAE❑ 3.RENEWALPERMIT _�-- ❑ e-TANK <br /> (SP-cib nasan) I. <br /> BUSINESS NAME 15amea FACILITY NAMEu DeA-tYJNe 9mmaa'bl 3. FACB.ITBJ: <br /> Y <br /> AlaD L7 45f- 153 .431. <br /> LOCATION WITHIN SITE(op--a <br /> L TANK DESCRIPTION <br /> (A scaled Plot plan with the locadtm of the UST system including buildings and lanclumla�s RITNENTALIZED TANK& L-i the local Yes) 0 434. <br /> TANKID# a3= TANK MANUFACTURER �� <br /> // v"Yes:ccnQleae one p4e <br /> ,� <br /> 436. UNE3 R OF COMPARTMENTS 437 <br /> DATER/h'tINSTALLEElD i15. TANK CAPACITY IN GALLONS / <br /> (YEA0) u/))� /< �4 O 439. <br /> ADDITIONAL DESCRIPTION(Fw and me only) <br /> II.TA`lK CONTENTS <br /> aeo. <br /> TANK USE 439. PETROLEUM TYPE <br /> E31. MOTOR VEHLCLE FUEL C]la. REGULAR UNLEADED [:3 2. LEADED [3 5- SET FUEL <br /> fESEL [36. .aVl-aTtON GAS <br /> (1lebsked mrylae Paokan TY9el [3 <br /> Ib. PREMIUM MEADED GASOHOL [3 99.OTHER: <br /> ❑ 2. NON-FUEL PETROLEU%t E211 MIDGRADE UNLEADED C3 4. aaz <br /> ial. CAST(Wm Haaadom Mmenab Invmmry page) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om H-nkm MeeAah leventay peel <br /> ❑ 4. HAZARDOUS WASTE <br /> ([=c Um!Oib <br /> UNTL-YOWN <br /> III.TANK CONSTRUCTION M3 <br /> TYPE OF TANK I. SINGLE WALL 3. SINGLE WALL WITH EXTERIOR S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> MEMBRANE LINER ❑95. UNKNOWN <br /> (Cheek one imm only) i. SINGLE WALL IN A VAULT 99. OTHER a44. <br /> ❑±. DOUBLE WALL i. CO\CRETE <br /> 95.I1NKNOWN <br /> „� . BARE STEEL 1. FBERGLASS/PLASTIC <br /> TANK MATERIAL-pvnar 4, STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE [3 99.OTHER <br /> ((.Leek ane vmionry) <br /> E3 2. STAINLESS STEEL E3W1I00% METHANOL REINFORCED PI-AST1C a4i <br /> TANK MATERIAL-mcondary mnit I. BARE STEEL <br /> 7, FIBERGLASS/PLASTIC 8- FRP COMI'CBI.E W/l00%METHANOL 95.IINKYOWN <br /> (Check oar imm only) 13 2. STAINLESS STEEL Q 4• REINFORCED EC D PCLAD LS IC(FRP) E3LASS 13 90- COATED STEEL JACKET ❑99. R <br /> 5. CONCRETEOWN w6. DATEINSTALLED M7. <br /> TANK INTERIOR LINING 1.RUBBER LI•lED 3.EPDXY LINING 5.GLSSLYLY <br /> ACG 95.E3 99.UNKNOWN <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING _2r6.UNLINED <br /> OTHER <br /> 44 <br /> Check orc imm onlvl3. <br /> OTHER CORROSION I.MANUFACTURED CATHODIC Q 4.IMPRESSED CURRENTCID PLASTIC Q 99.OTHER95.UNKNOWNaae. DATE INSTALLEDPROTECTION PROTECTION aR <br /> If lieablal 2.SACRIFICIAL ANODE TYPE 45t OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED sso. [02 1-ALARM C13.FILL TUBE SFM OFF VALVE <br /> (Check an dm apply) I.SPIL"L 2.DROP CTUBEAINMENT C1 Z HALL FLOAT_ E3 4.EXFMP'T <br /> ❑3.57RICEA PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring Provzm shall be submitted to the local ae/.) DER <br /> as4. <br /> 4s3. I DOUBLE WALL TANK OR TANK WrM BLAD <br /> IF SINGLE W ALL TANK (Cheek otae imm only) <br /> (Check all that WPlr) ❑5_MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) Q 6•VADOSE ZONE E3 2_CONTINUOUS INTERSTITIAL MONTTORING <br /> ❑2.ALTOMATIC TANK GAUGING(ATG) Q 7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑3.CONTINUOUS.ATG <br /> ❑i. STATISTICAL INVENTORY RECONCILIATION Q S.TANK TESTING <br /> (SIR)-BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TA`(K CLOSURE INFORIVIATION/ PERER`iEN'T CLOSE. TANK <br /> AN PL DC�INERT MATERIAL? as,. <br /> ass. ESTIMATED QUANTTTY OF SUBSTANCE RENI.ALNIYG Q Yes ❑ No <br /> ESTIMATED DATE LAST USED(YRMO/DAY) pllom <br /> � <br /> Rev.02116M <br /> _ http:/I w .unidocs.org <br />