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U NIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (A.0 Pages par tank) <br /> ❑dN 0�. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ <. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) IPERMANENTLY CLOSED ON SIT <br /> (Coeµor 2arrloNy) / Ii <br /> 0.RENEWAL PERMIT (Spaciynuon-brlocN use omy) (Spc✓y Nenpa-brlocN un only) ❑ 8. TANK REMOVED UO <br /> LIID t <br /> BUSINESS"ME(Barna as FACILITY NAME or DBA.Ddw Bwieua A3) FA2ITY I <br /> 9DJDj 5kfOp Ib <br /> TIpNJyTNI TE( O <br /> ti <br /> 1.TANK DESCRIPTION <br /> TANK MANUFACTURER <br /> ANUFACTURER COMPARTMENTA <br /> LIZED TANK pAb Yea rops No <br /> TANK IOt oa <br /> V o GWFJ VuKhow <br /> DATE INSTALLE (YEA RRAO) TANK CAPACITY IN GALLONS NUMBER OF OOMPARTMENTS <br /> l�15 <br /> ADDI L DESCRIPTION IF tical u P*? <br /> IL TANK CONTENTS <br /> TANK USE A32 PETROLEUM TYPE ❑ 5. JET FUEL <br /> \ISI t MOTOR VEHICLE FUEL ❑L. REGULAR UNLEADED ❑ 2. LEADED <br /> prmanao.cwoft PafmMum rY ) 1p, PREMIUM UNLEADED 21 DIESEL DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NOWFUEL PETROLEUM 1a MIDGRADE UNLEADED ❑ A.GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PROOUCT COMMON NAME(Fpm Hazalloui MahrMla Inventory papa/ GS Y(ham Nezeldoua Mafenala In✓.nfaypwa) <br /> ❑ A.UA 010 S WASTE(InckKNa <br /> Uaae 091 <br /> 21 liumam <br /> 111.TANK CONSTRUCTION <br /> F <br /> NK C2 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 2. DOUBLE WALL 0 1. SINGLE WALL IN A VAULT % OTHERRIAL-plkevyNnk L� BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE95. UNKNOWN <br /> emo vy) ❑ 2. STAINLESS STEEL 0 A STEEL CLAD REINFORCED IFIBE GILkSS � 8FRP COMPATIBLE WI1W%METHANOL ❑99OTHER MATERIAL NM 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE Wil 60%METHANOL 095. UNKNOWN <br /> (C Faµom Item onM ❑ Z. STAINLESS STEEL ❑ A. STEELCUO WIFIBERGUBS ❑ 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> 1�, REINFORCED PLASTIC(FRP) 0 10. COATED STEEL <br /> rJ K ❑ B CONCRETE <br /> DATE INSTALLED <br /> TA NN INTERIORUNING 0 t RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS UNING 0 9. UNKNOWN433 <br /> OR COATING O 2. ALKYD LINING ❑ C PHENOLIC LINING ❑ 6. UNLINED 099. OTHER <br /> (FwbW ass o <br /> p0 DATEINSTALLED <br /> OTHER CORROSION ❑ T MANUFACTUREDCATHODIC ❑ 1 FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN AM <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ <. IMPRESSED CURRENT 0 99. OTHER (Forbaluse oNy) <br /> (Clrµona Ba .m ❑ 2. SACRIFICIAL WOE <br /> SPILLANDOVERFILL 0YEAR INSTALLED TYPE(Fvb lussoMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CMµM Mat apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM __ ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT_ ❑ A. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> _ IV. TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER(Chock ons dem w ): <br /> M SINGLE WALLTANN CRack W that <br /> ❑ <br /> I. MSUAL(EXPOSEOPORTION ONLY) ❑ 5. MANUAL TANK GAUGING(NITS) ❑ J. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSEZONE ❑ 2. CONTINUOUSINTERSTITIALMONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ A. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ e. TANKTESTING <br /> BIENNIAL TANK TESTING ❑p9. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> Kj)h <br /> ESTIMATED DATE\-I- (YR/MOIDAY) ESTIMATEDQLW BSTANCE EMAINING 435 TANK FILLED'ATTM INERT MATERIAL? <br /> V F. ll.��J <br /> pallona OVta [IN. <br /> -Wot fl <br /> /�- � � Y'V 5� �E�(}�1 � FormeNY�Fartn B <br /> CUPAFORM(4199) �k.�j �(A,5 vJ- �M-a� Vt.6 ea A�( ' <br />