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UN ;D PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page 2 of 3 TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4,AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 439. (Check one it=only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify mason) (Swapy 8.TANK REMOVED BUSINESS NAMES.as FACILITY NAME n DEA-mica Bushes M) 3. FACILYI7ID: I. SBC SKTNCAI2 UE132 LOCATION WITHIN SITE(opumail 451. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings mid landmarks shall be aublNnted m t11e 10e91 agony TANK ID 432_ TANK MANUFACTURER 433. COMPARTM ENTALIZED TANK Yea No 434, JOOR Ir"Yea,"conpkde ono page for uah oomperreme. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 456. NUMBER OF COMPARTMENTS (YEAR/MO) 437 . 1988 2,000 ADDITIONAL DESCRIPTION(For kcal uu only) 433. IL TANK CONT$NTS TANK USE 439. PETROLEUM TYPE 40 ® I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED El 2, LEADED [3 5. LET FUEL (Ifch.k.d,cmv&d.Pehol4am Type) [I Ile. PREMIUM UNLEADED 113. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ia. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (RanHmardou Muaiah lmmlory prge) 441. CAS#(ham Fluudaua MetenLLrinwaory pogo) M1. ❑ 4. HAZARDOUS WASTE (Inuudan Ueed OIQ ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK C 1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR El 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check am item only) MEMBRANELINER [3 95. UNKNOWN 9 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANKMATERLIL-primary kmk ®1. BARE STEEL U 3. FIBERGLASS/PLASTIC 5. CONCRETE 0 95.UNKNOWN 444. (Chmk.-hoononly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/PIBBROLASS ❑a. FRN COMPATIBLE ❑99.OTHER REINFORCEDPLASTIC FRP Wil 00%METHANOL TANK MATERIAL-secondary knk ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTOL.E W/I W%METHANOL U 95.UNKNOWN 445. (Check one learn only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/MHRGLASS []9. PRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINIIVO ❑5.GLASS LINING 95.UNKNOWN 446, I DATE INSTALLED 447. OR COATING ❑2.ALKYD LIVING ❑4.PHENOLIC LINING N 6.UNUNED ❑99.OTHER Chock.I=od OTHER CORROSION Lj I.MANUFACTURED CATHODIC 13 3,FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN "s, DATEINSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER 06/03 fA Iloebk 2.SACRIFICIAL ANODE SPE,L AND OVERFILL YEARINSTALLED 439. TYPE 431. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check a8 out apply) ®l.SPILL CONTAINMENT 1988 to L ALARM 1988 ®3.FILL TUBE SHUT Ott'VALVE 1988 ®2.DROP TUBE 1988 ®2.BALL FLOAT 1988 ❑4.EXEMPT ®3.STRIKER PLATE 1988 W.TANK LEAK ETECTTON (A description of the monitoring program shall be submitted 4o the local_- ane ) IF SINGLE WALL TANK 453 W DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check all that apply) (Check one item only) ❑1.VISUAL CEXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) C 1.VISUAL(SINGLE WALL IN VAULT ONLY) C 2.AUTOMATIC TANK GAUGING(ATO) C 6.VADOSE ZONE N 2.CONTINUOUS INTERSTITIAL MONITORING C 3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING C 4.STATISTICAL INVENTORY RECONCILIATION ❑a.TANK TESTING (SIR)+BIENNIAL TANK TESTING C99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 435' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457, gallon¢ ❑Yee ❑ No RECEIVED FEB-11-04 15:09 FROM-9168581011 TO-KLEEMAN ROEBBELEN PAGE 17