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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> ' @w pages w tank) <br /> ..��/f Pagof <br /> e _ <br /> TYPE OF ACTION ❑1.NEW UJSITE PERMIT ❑ C AMENDED PERMIT 4 CHANGE OF INFORMATION) ❑ IL TEMPORARY SITE CLOSURE <br /> (CMck am ifem only) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SFetifYmaspn-Wloc .ow (SpaPfy ill Mo-fon local use oNy) ❑ 8. TANK REMOVED 0.70 <br /> BUSINESS NAME(Same as FACILITY NAME of DBA-Dp Sa8 mss As) FACILITY 10 Y 1 <br /> LOCA aa, <br /> K.TANK DESCRIPTION <br /> TANK 100 TANK MANUFACTURER COMPARTMENTAUZEO TANK ❑ Yes ❑ No <br /> If Yes'.oompiMe ono page W aatll pompeflmMt. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Foflo use coW <br /> II.TANK CONTENTS <br /> TANK USE AM PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JEF FUEL <br /> (p ma'kaf compleM PMm Type) C3 lb. PREMIUM UNLEADED ❑ 3. DESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1M MIDGRADE UNLEADED ❑ 4 GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASMfmI 'Wes COMMON NAME(eom Haa.m shfte slnWnlpfypp,) CASapbm MazaNMS MAMW,MvefXaypp) <br /> USM 04 <br /> 11% UlKlOM <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL Cl 3. SINGLE WALL VATH ❑ 5. SINGLE WALL VATH INTERNAL BLADDER SYSTEM <br /> Icl op kem aHyl Cl 2. DOUBLEVIAIL EXTERIOR MEMBRANE LINER ❑0. UNKNOWN <br /> ❑ 4. SINGLE WALLIN A VAULT ❑W. OTHER <br /> TANK MATERIAL-pmary tank Cl t BARE STEEL ❑ 3. FIBERGLASSIPLASTIC ❑ 5. CONCRETE ❑95 UNKNOWN <br /> (CIMs9.Aaa omyl ❑ 2. STAINLESS STEEL ❑0. STEEL CUD VNRI RGLASS ❑ 8. FRP COMPATIBLE W,00%METHANOL Cl W. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANKMATERIAL sepp0aIylank ❑ 1 ERRE STEEL ❑ S FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE MIW%METHANOL 095. UNKNOWN <br /> (CAsck pm"M omy) ❑ 2. STAINLESS STEEL ❑ a. STEEL CUD WIFlBERGLASS ❑ 9. FRP W*N CORRODIBLE JACKET ❑8B. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER UNED ❑ 3. EPDXY UNING ❑ 5. GLASS UNING Cl 9& UNKNOWN G GATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKVOUNING Cl 4. PHENOLIC UNING ❑ S. UNUNED 1399. OTHER <br /> om Aern 1 lForhk-el uaa <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHOOIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 098. OTHER <br /> (CMUr one kem aHyl ❑ 2. SACRIFICIAL ANODE (AV�peOw <br /> SPILLANDOVERFILL YEAR INSTALLED TYPE(Fw_useofay) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (CMckaamNapply) ❑ 1. SPILL CONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(CMckaa 0W a IF DOUBLE WALL TANK OR TANK WITH BLADDER(OfNcx oiro Item onlY11 <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING INTO) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(AM) ❑ a. VADOSE ZONE Cl 2. CONTINUOUSINTERSTITIALMONITORING <br /> ❑ 3. CONTINUCUSATG ❑ T GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATSTCALINVENTORYRECONGIJATON @IRI' ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING ON. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE ST U (V Y) $TIIMTED QUANT W OF SUBSTANCE REMAINING 435 TANK FlLLFD`MTI INERT MATERML'! <br /> ZIpM ons Cl Yee i Ne <br /> CUPAFORM(4B9) FmLlerq SWRCS Form 6 <br />