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UNIFIED PROGRAM CONSOLIDATED FORM <br /> ' <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 "l TANKS <br /> 05/55 (hw pages pe,tank) <br /> Page _ of _ <br /> TYPE OF ACTION NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Chock one Rem only) <br /> 113.RENEWAL PERMIT ❑ T PERMANENTLY CLOSED ON SITE <br /> (Spea/y/sason-Iorlpcal use aHyl (Speory Chonpe-Mlocal use anlk9 ❑ 6. TANK REMOVED a3D <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Doing Business AS) FACILITY ID• 1 <br /> Z C <br /> LOCATION WITHIN SITE -nMl 431 <br /> TANK 10 Y TANK MANUFACTURER I.TANK DESCRIPTION <br /> �/ COMPARTMENTALIZED TANK ❑ Yeso <br /> /-�A.t` 01 i vwj If Na-,pp"I me page w eachmmpaNnenl. <br /> DATE INST�ALLgE�D)(YEARdO) TANK CAPACITY IN GALLONS (v NUMBER OF COMPARTMENTS <br /> OOO <br /> ADDITIONAL DESCRIPTION(F e-mmar use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑J 1. MOTOR VEHICLE FUEL ❑1& REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (6muMe0,I.PlIe s Polices.Type) ❑lb PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 1 NON-FUELPETROLEUM ❑1<. MIDGRADEUNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3.CHEMICALPROOUCT <br /> ❑ 4. HAZARDOUS WASTE(trclWea COMMON NAME(fpm Harallow Mafedals Inr nforyp ge) CAS Y(ftm Hasallous MafeNb InuenNe pepe) <br /> Usarl Oto <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK -0�1 SINGLE WALL ❑ 3. SINGLE WALLWATH ❑ & SINGLE WALL VATH INTERNAL BLADDER SYSTEM <br /> (Chock ores item only) ❑ 2, DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT 1199. OTHER <br /> TANK MATERIAL-primary lank 444BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Chock acre dem orxN ❑ 2 STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGUSS ❑ B. FRP COMPATIBLE W/100%METHANOL 11 OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL mcon6ary wk ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ B. FRP COMPATIBLE W/100%METHANOL 0 9. UNKNOWN <br /> (Chock.dem only) ❑ 2 STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9, FRP NON-CORRODIBLE JACKET ❑N OTHER <br /> REINFORCED PLASTIC(FRP) 1110. COATEDSTEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 3, EPDXY LINING ❑ 5. CUSS LINING ❑95. UNKNOWNa33 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 116. UNLINED ❑99. OTHER <br /> (CnecF one item on Fwlocal use only) <br /> OTHER CORROSION C11 MANUFACTURED CATHODIC IJ3. FIBERGUSS REINFORCED PLASTIC ❑95. UNKNOWN 431 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> (Check one Rem only) ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> Y ❑ 2. SACRIFICIAL ANODE (Fwlocal use onN) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(F./local use only) OVERFILL PROTECTION EQUIPMENT,YEAR INSTALLED <br /> (Chepk ad lhat appy) ❑ 1 SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3 FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ A EXEMPT <br /> ❑ 3. STRIKER PUTS <br /> V. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK VATH BLADDER(Check one Item onW. <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING INTO) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING 1199, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> paM s ❑Yes <br /> ❑No <br /> t 8114101 <br /> CUPAFORM(4/99) '"No, 1/1 Formerly SVJRCB Forth B <br />