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JOFIED PROGRAM CONSOLIDATED FORD TANK; 11 / PR#: UNDERGROUND STORAGE TANKS -TANK PAGE 1 Lgza FAC#:a tank) � TYPE OF ACTION I NEW SITE PERMIT❑ E] 4 AMENDED PERMIT Page1,f3 Y3^`Ac` 1 (L�'S^Ii ven WY) ❑ SCHANGE OF INFORMATION ❑ 6TEMPORARY SITE CLOSURE )I0-3+ o C] 2 PERMANENTLY CLOSED ON SITE Jv ❑3RENEWAL PERMIT [5}LTANK REMOVED UO BUSINESS NAME(sme as FACILITY NAME w DBA-Doing Bmmwa As) FACILITY ID: PR#: I 3 LOCATION WITHIN SITE(opu ) 43 "kuz" -4— r �-t l,&zanJel a Vj-0-u - PHONE 1.TANK DESCRIPTION(A stated plot plan with the location of the UST system including buildings and Iandr arks shall be submitted to the local agency.) TANK �(IDN T 7 452 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes .E No 4R ' If"Y®:mnPbttow PVe 6x ra�wnpvmac DATE INSTALLED(YEAWMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 012 P O d ADDITIONAL DESCRIPTION(rw ted newsy) 438 D.TANK CONTENTS TANK USE 439 PETROLEUM TYPE uo ❑ I.MOTOR VEHICLE FUEL ❑ I a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If�Pewkxn TSpc) ❑ Ib.PREMIUMUNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ It.MIDGRADE UNLEADED ❑ 4.GASOHOL @j,99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAMEEon IIn Maroiale mem ❑ ( Iwr P+ad 441 CAS#(6om Hnu.aom Matniab brvmwy Page) ux d.HAZARDOUS WASTE (keludw U.d Oil) IPL95.UNKNOWN III.TANK CONSTRUCTION TYPEOFTANK Ed LSINGLE WALL ❑ 3.SINGLE WALL WITH ❑ S.SINGLE WALL WITH INTERNAL BLADDER SYSTEM u3 (Cswkmeimnmy) EXTERIOR MEMBRANE LINER 095.UNKNOWN ❑2..DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ ".OTHER TANK MATERIAL-primary tank esl I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑ 95.UNKNOWN 444 (Cliwk ow irrnwdy) ❑ 2.STAINLESS STEEL ❑ STEEL CLADW/FIBERGLASS ❑ S.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(I") ❑ 99.OTHER TANK MATERIAL-scwndaU sank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 IOxak meimnmy) ❑2.STAINLESS STEEL ❑ 4.STEEL CLADW/FIBERGLASS ❑ B.FRPCOMPTIBLEW/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATEDSTEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑ 3.EPDXY LININGa42 OR COATING ❑ 5.CLASS LINING �95.UNKNOWN 445 DATE INSTALLED (CldmeiumaJy) ❑2ALKYD LINING ❑ 4PHENOLIC LINING ❑ 6UNLINED ❑99.OTHER (Pwkd wee4y) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN ae DATE INSTALLED N9 PROTECTION IF APPLICABLE PROTECTION (Ch> iw wdy) ❑ 41MPRESSEDCURRINT E]"OTHER ❑ 25ACRIPICW.ANODE (Fw lowl.mly) SPILLANDOVERFILL YEAR INSTALLE450 TYPE(bwtwemy) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Ltwk as thv qqb) ❑ I SPILL CONTAINMENT ❑ IALARM3 FILL ❑ 2DROP TUBE ❑4EXE TUBE SHUT OFF VAU ❑ 3STRIKER PLATE ❑ FLOAT2 BALL ❑4EXEMPT FLOAT IV.TANK LEAK DETECTION(Admagdmofth mminniegpmgam s6ellbe eubn:uNto d.kw yeay.) IF SINGLE WALL TANK(C Amat ypy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4M ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (CTwk w wy) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 2 GROUNDWATER ❑2 CONTINUOUS INTERSTITIA.MONITORING ❑4STATLSTICALINVENTORYRECONCILIATION ❑ 8TANK TESTING ❑3 MANUAL MONITORING (SIR)8MC41AL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST U ED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE RENAMING 455 TANK FILLED WITH INERT MA 452 Q IX ( Q 3 "��' ❑Yes No 0 UPCF(12/99 revised)