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'MAY 11 2005 <br /> UNDERGROUND STORAGE 'TANKS -TANNyjA4gS/K1N COLATY <br /> GENCY �^gey per tank) <br /> Page_of <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (Check one it.ony) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify won) (Specify won) ❑ S.TANK REMOVED <br /> 3. FACILITY ID: 1. <br /> BUSINESSNAME(Same uFACILITY NAhg mDBA-Doing Bmivecs As) �r <br /> LOCATION WITHIN SITE(optimal) 431. <br /> / axv Lf <br /> 7 <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall be subautted to the local agency.). <br /> TANK ID# 432. TANK MAN[ipACTURER 631. COMPARTMENTALIZED TANK ❑Yes IV No 434. <br /> j [f"Yes,"comPleie one pegc for each wmpermtmt <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. <br /> (YEAR/MO) Xw <br /> ADDITIONAL DESCRIPTION(For local me only) 435. <br /> IL TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE 6°0' <br /> 1, MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL <br /> 0fcbecked,complex Pcwlemn Type) 1�1b. PREMIUM UNLEADED [13. DIESEL [16. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (tram Hemmm-Mmmms Imenmsy page) 611' CAS#Oimm Hamrdom Mmenels Im,em r page) 0°2' <br /> ❑ 4. HAZARDOUS WASTE - <br /> (InelWesUsedOB) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERVAL BLADDER SYSTEM 443. <br /> (Check ane item only) MEMBRANE LINER ❑95. UNKNOWN <br /> 11 <br /> 2. DOUBLE WALL [1 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary nine ❑1. BARE STEEL ❑3. FIBERGLAS5/PLASTIC ❑5. CONCRETE [395.UNKNOWN 444. <br /> (Check one item may) [12. STAINLESS STEEL . STEEL CLAD W/FIBERGLASS 118. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC(FRP) W/100°h METHANOL <br /> TANK MATERIAL-secondary tank U 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNO WN 445. <br /> (Check one item only) ❑2. STAINLESS STEELLX4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) [110. COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING ❑1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINI4G ❑95.UNKNO WN 446. DATE INSTALLED "7. <br /> OR COATING [12.ALKYD LINING 4.PHENOLIC LINING [16.UNLINED ❑99.OTHER <br /> Check one item onl ) <br /> OTHER CORROSION [11.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 44& DATE INSTALLED 449. <br /> PROTECTION PROTECTION [14.RAPRESSED CURRENT [199.OTHER <br /> (If A lieable) ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVEAI'IIt2. <br /> STALLED 450. TYP 451�. OVERFILL PROTECTION EQUIPMEM: YEAR INSTALLED 452. <br /> (Check all that apply) .SPILL CONIAINMENT� S'.JT ❑I.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE <br /> DROP TUBED- ,�'L+�L ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> .STRIKER PLATE 'e- <br /> IV.TANK LEAK DETECTION <br /> (A description 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 454. <br /> (Check all that apply) (Check one item only) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MIG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTTTIAL MONITORING <br /> [13.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION 118 TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> y.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) °55. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 056 TANK FILLED WITH INERT MATERIAL? 451. <br /> galpm ❑Yes ❑ No <br /> 61 <br />