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s UNIF. D PROGRAM CONSOLIDATED FOR <br /> FF. TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> w���/'•y� (Ino pages per lank) <br /> r`VY Vv"v cV I V' LY" Pe9e _ of _ <br /> TYPE OF ACTION EW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Check ore On,oNy) ❑ ?. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT ISpecilyreason-brlacalu»only) (SpecirycMrpe-mrlocalusnonly) ❑ S. TANK REMOVED 030 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-DaIN Business As) FACILITY ID l 1 <br /> 00L3il09 <br /> LOCATION WITHIN SITE(OpBolr7_ . � A s f- ��y 1 ' D 5155 / <br /> 2 S W 1.TANK DESCRIPTION <br /> TANK IOM TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea ❑ Na <br /> s 1 1A (/ J �nplal.ane page Wearth rnmp.Hment. <br /> DATE INSTALLED(YEARIMO) TANK PPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 5000 <br /> ADDITIONAL DESCRIPTION(For local use anly) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (N.aad.compbmp Inaleem Type) �1E. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1a. MIDGRADE UNLEADED ❑ a.GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(Gma HaurdOw MaledalelnvenWypage) CASa(rmm Hasalloua McMdala~RIWpape) <br /> ❑ 4. OO <br /> AZARUS WASTE(Includes <br /> Ue.d Dn <br /> 95 UNKNO.01 <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK gr 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> EXTERIOR MEMBRANE LINER C1 95. UNKNOWN <br /> (DMCN oM Ilam oNy) C1 2. 001.81-9WALL 0 4. SINGLE WALL IN A VAULT <br /> C399 OTHER <br /> TANK MATERIAL prkoary Wk t BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE [3 95. UNKNOWN <br /> (Cneckoredemanlsg ❑ 2. STAINLESS STEEL 04 STEEL Cl-AD PLASTIC(FRP) <br /> S [1 8. FRP COMPATIBLE WI 100%METHANOL ❑99. OTHER <br /> REINFORCED <br /> TANK MATERIAL-secondary lank 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WIIW%METHANOL ❑95. UNKNOWN <br /> (Check 0e8em only) ❑ 2. STAINLESS STEEL 0 4 <br /> REINFORCED VaFIBERGILASS <br /> LASTIC(FRP) C1 9' FRP NON-CORRODIBLE JACKET C3 99. OTHER <br /> ❑10. COATED STEEL <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATINGD 1. RUBBER LINED ❑ 3. EPDXYLINING ❑ 5. GLASS LINING ❑95. UNKNOWNtl3 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED El 99, OTHER (Forrocal use on <br /> Mck oM ibmo ) DATE INSTALLED <br /> OTHER CORROSION 0 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT El 99. OTHER (Forbcaluu only) <br /> (OMck one it..only) ❑ 2. SACRIFICIALANODE <br /> $PILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT',YEAR INSTALLED <br /> (CAeckatllNalapply) ❑ 1. SPILL CONTAINMENT ❑ 1. AURIN __ D 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 ClrecN atl 1Nel a IF DOUBLE WALL TANK OR TANK WITH BLADDERCMck oM item o <br /> ❑ ❑ S. MANUAL TANK GAUGING(INTO) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY( <br /> 1, VISUAL(EXPOSED PORTION ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUCUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING - 0 OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRNIOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED'MTH INERT MATERIAL? <br /> pallona ❑Yes ❑Na <br /> CUPAFORM(4/99) • Formerly SVVRCB Form B <br /> • (� aKlo(foi <br />