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,.�IFIED PROGRAM CONSOLIDATED FOR1Y,,,d -'I 3I TANK: I PR#: UNDERGROUND STORAGE TANKS - TANK P {{�,� PAC#_ l U 3 �.0(L(two pages per rank) Page 2 of l TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE (L oobuem any) ^^ " `" ❑ 7 PERMANENTLY CLOSED ON SITE ❑/RENEWAL PERMIT ( h I 1 1 oay)�' (Sp 5'�+® f IaI m1yT• J}ddV _ 87ANK REMOVED +39 BUSINESS NAME(samsa FAcwrrNAMeorDat-Wwg emioms As)µ_ µFACILITY ID: PR#: r UNY je rvres ' d� LOCATION WITIUPI SITE(oPoon 431 9 ( 3 l 4 r 4� ' Yi-6 • PHONE 1.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and land=rks shall be subndtted m the local agency.) Z ID# _ D (� + Z TANK MANUFACTURER +33COMPARTMENTALIZED TANK El Yes ❑No 4s+ LL If"Ya',mmpWeorc Page fa ucL mvgvwmt DATE INSTALLED(YEAR/MO) 455 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(Fobnlusemiy) Cr P\ 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE sµ9 ❑ L MOTOR VEHICLE FUEL ❑ la REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (rf�Pa -Tra) ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(6om H=a w Mascdars rwrnww ge) a1 CAS#(fimm R m Mawnah invmo page) 412 ❑4.HAZARDOUS WASTE 0oo1Wm USW DID ❑95.UNKNOWN HI.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 4D (C kmeionosly) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN [:12.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-Primvytank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑95.UNKNOWN +++ ((,tsckmatwnony) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑",OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE [:195.UNKNOWN ++' (C omimnony) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/10()%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑ S.GLASS LINING El 95.UNKNOWN 446 DATE INSTALLED A7 OR COATING (Cbakomi.o*) E] 2ALKYDLINING ❑4PHENOLIC LINING ❑ 6UNLINED El 99,OTI$R loml (Fm me omr) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN µ4s DATE INSTALLED A9 PROTECTION IF APPLICABLE PROTECTION Chsckonttan El IMPRESSED CURRENT El 99 OTHER ( °ny) ❑25ACRIFICIAL ANODE (Fmbral moody) SPILL AND OVERFILL YEAR MSTALLE450 TYPE(Ioalmeoly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 451 (C A�wb) ❑ 1 SPILL CONTAINMENT ❑ I ALARM ❑3 FILL TUBE SHUT OFF VALs ❑ 2 DROP TUBE ❑ 2 BALL ❑4 EXEMPT ❑ 3STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A emoipom ofaa monitoring pmgr4m sha8 be submiueu m sw lotal ageony) IF SINGLE WALL TANK(CTakaB Dns RPy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Click 9m aem ody) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIA.MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTENATEDD IE LAST US ( O/DAY) 45s ESTIMATED QUANTrrY OF SUBSTANCE REMAEVING 456 TANK FBI ED WITH INERT MATERIAL? +5> ' ❑Yes ❑No UPCF(12/99 revised)