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UNDERGROUND STORAGE TANKS -T,AN� AQiU1N C N5n <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AM7ENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (Check oec item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Spedfymuon) (Specify mason) ❑ 8.TANK REMOVED <br /> BUSINESS NAME(S.meu FACRIfY NAMIE or DBA-Doing Busi As) 3. FACII,ITY ID: t' <br /> GC 4 <br /> + i <br /> LOCATION WITHSITE( uonil) 431. <br /> IN <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# U2. IANKPLkNUkACIURER 433. COMPARTMENTALIZED TANK ❑Yes No 434. <br /> i4 If"YR"w pine one page fm®ch compo neot <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS <br /> 43]. <br /> ADDITIONAL D SCRHMON(Foe Ion]..only) 438' <br /> H.TANK CONTENTS <br /> yyyT���A///NK USE 439 PETROLEUM TYPE <br /> xDp 1. MOTOR VEHICLE FUEL ❑I& REGULAR UNLEADED yyy❑,///2. LEADED [15. JET FUEL <br /> (If checked.coo lee,Petroleum Type) L3 lb. PREMIUM UNLEADED ,ty 3. DIESEL [16. AVIATION GAS <br /> El 2. NON-FUEL PETROLEUM ❑Ic. MBDGRADE UNLEADED ,❑`4. GASOHOL 1399.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (linin Hmmou Matomis,Inventorr wge) 461CAS#(Rmn Hv ou Wflenals loventmy Page) 462 <br /> ❑ 4. HAZARDOUS WASTE <br /> (Include used can <br /> ❑ 95.UNKNOWN <br /> M.TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> (Check one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [199. OTHER <br /> TANK MATERIAL-pm e,tank I. BARE STEED ❑444...,,,���3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. <br /> (Check om hem oNy) ❑2. STAINLESS STEEL Ik5 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: <br /> ,` REINFORCED PLASTIC(FRP) W/100%METHANOL <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL y❑3. FIBERGLASS/PLASTIC 6. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. <br /> (Check ane item `v <br /> only) ❑2. STAINLESS STEEL . STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> [35. <br /> 5. CONCRETE <br /> TANK INTERIOR LINING ❑1.RUBBER LINED 3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN W. DATE INSTALLED 44]. <br /> OR COATING ❑2.ALKYD LINING 4.PHENOLIC LINING [16.UNLINED ❑99.OTHER <br /> (Check one item onl <br /> OTHER CORROSION [11.MANUFACTURED CATHODIC "' FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. <br /> PROTECTION PROTECTION [:34.IMPRESSED CURRENT [199.OTHER <br /> (If A livable) ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YFA�R INSTALLED 450. E 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. <br /> (Check ell that apply) 1.SPH I.CONTAINMENT `7`1/ ] [12.BAL.ALARM OAT_ ❑4.FILL TUBE SHUT OFF VALVE <br /> 2.DROP TUBE <br /> PT <br /> 3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> of the monitoring program shall be submitted to the local agency.) <br /> IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 4s4. <br /> (Check all that apply) ( one item only) <br /> [11. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑VISUAL(SINGLE WALL IN VAULT ONLY) <br /> [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING <br /> [13.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING <br /> [14.STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099.OTHER <br /> V.TANK CLOSURE INFORMATION/,PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 411, TANK FILLED WITH INERT MATERIAL? 457. <br /> gallons ❑Yes ❑ No <br /> 61 <br />