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U NIF IED 1'H UUHA M L. UNS UL UA I LUf U KM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Aeopages per tank) <br /> Page _ of _ <br /> TYPED FACTION r I. NEWSITE PERMIT r 4. AMENDED PERMIT yk5. CHANGE OF INFORMATION) r 6. TEMPORARY SITE CLOSURE <br /> (Chexkoneltem only) r7. PERMANENTLY CLOSED ON SITE <br /> r3. RENEWALPERMR (Spedly reason-brlocal use Doty) (Spedo,change-W tical use only) <br /> 1-S. TANK REMOVED 430 <br /> SUSINES NAME(Same as FACILITY NAME or OSA-Doig Business As) 3 ACIL'! a1 ' <br /> L.� ews <br /> LOCAr1ONWTHIN STTE(OpSonap 431 rrs�� --�.. <br /> LA"' �.'B)RT(4�1�" �237a`�d'pTeAJllat}4ar-( 1 aF t(fLk '.: sysfarr[NiirN4g171Upc✓fili ano=7aiHmarfcyshagba'xb6irll Ldt9"fndbt"ahagERZ3" CJI." s�''`.��"..z',?i,4 <br /> WN <br /> _432 TANKMANUFA Ipen -... .... _. .. <br /> L (�TI � 433 COMPARTMENTALIZED TANK rYes VN. 434 <br /> N AYese complele one page for each compartment. <br /> DATEINSTALLED(YEARA40) 435 TANKCAPACITYIN O S 436 NUMBER OF.COMPARTMENTS 437 <br /> ADDI IONALOESCRIPTION(Forbcal use MW 438 <br /> -.. <br /> JJJJ iANKtISE 439 PETROLEUM TYPE 440 <br /> 1. MOTOR VEHICLE FUEL FIM REGULAR UNLEADED r2. LEADED 1-S JET FUEL <br /> !marked,complete Pebolsum Type) -1t•. PREMIUM UNLEADED r 3. DIESEL r B AVIATION FUEL <br /> r2. NONFUEL PETROLEUM rsa MIDGRADE UNLEADED r4. GASOHOL r99. OTHER <br /> r3- CHEMICAL PRODUCT COMMON NAME Ifmm Hazardous Materials Ir ntcrypage) 441 CAB#i1rorn Hazardous Maheialslmenkaypege) 442 <br /> r d. HAZARDOUS WASTE(Includes <br /> es <br /> olp <br /> 1-95. UNKNOWN <br /> TYPE OF TANK ]' 1. SINGLE WWLL r 3. SINGLE WALL WITH r S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> 'Check one item only) K2 DOUBLE WILL EXTERIOR MEMBRANE LINER 1-95. UNKNOWN <br /> r 4. SINGLE WALL IN A VAULT <br /> 1-99. OTHER <br /> rANKMATERIAL-Pdmesylenk r 1. BARESTEEL �Y4 FIBERGLASS/PLASTIC 1-5. CONCRETE r95. UNKNOWN 444 <br /> Check one item onW r2 STAINLESS STEEL r4. STEEL CLAD BERGLASS 1-8. FRP COMPATIBLE W1(N14 METHANOL x90. OTHER <br /> REINFORCED PLASTIC <br /> (FFRRP <br /> A.NKMATERIAL-secondary r 1. BARE STEEL VA FIBERGLASS/PLASTIC B. FRP COMPATIBLE M00%METHANOL r95. UNKNOWN 445 <br /> uric <br /> r 2 STAINLESS STEEL r A STEEL CLAD r 9. FRP NON-CORRODIBLE JACKET reg OTHER <br /> :heck Dna item only) WIFIBERGLASS x10. COATED STEEL <br /> REINFORCED PLASTIC <br /> (FRP) <br /> 1-5. CONCRETE <br /> ANK INTERIOR LINING r 1. RUBBER UNED r 3. EPDXY LINING r 5. GLASS LINING r95. UNKNOWN445 DATE INSTALLED 447 <br /> R COATING <br /> 1-2 ALKYDLINING rd PHENOLIC LNItJG )KA. UNLINED r99. OTHER <br /> :heck one item on Forku'al usa oN) <br /> THER CORROSIONDATE INSTALLED <br /> 20TECTI0NIF APPLICABLE r 1. MANUFACTURED r3. FIBERGLASS REINFORCED PLASTIC 1-95. UNKNOWN 448 449CATHODIC r 4. IMPRESSED CURRENT r99. OTHER <br /> :heck one item DAW PROTECRON <br /> IF 2 SACRIFICIALANODE (Forbcaf use ortlr) <br /> 'ILL AND OVERFILL YEAR <br /> /INSTALLED <br /> � TYPE(Forlocaluseonly)451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> 'heck all that appal ✓v 4 <br /> 60 1 <br /> SPILL CONTAINMENT f .J{-,7 r 1. ALARM 1L8, FILL TUBE SHUT OFF VALVE <br /> . lre DROP TUBE ('�(�(� r2 BALL FLOAT 1-4. EXEMPT <br /> /�P. STRIKER PLATE S C)co <br /> 'LEACDETECIlONCrh J--, "P n_"t. mo rfpn/Ig„ <br /> IF SINGLE WALL TANK(Check 89 lhaf apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check cneitem only): 454 <br /> ` 1, VISUAL(EXPOSED PORTON ONLY) 1-5. MANUALTANK GAUGING(MTG) rt. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> `2 AUTOMATICTANKGAUGING(ATG) r6. VADOSE ZONE 2 CONTINUOUS INTERSTTTIALMONITORING <br /> 3. CONTINUOUS ATG r 7. GROUNDWATER 1-3, MANUAL MONITORING <br /> 4. STATISTICAL INVENTORY RECONCILIATION(SIR). rB. TANKTESTNG <br /> vs u�si.reuureenun <br /> ;} y TANK CLOSURE INFO NI-PERTIANENT CLOSURE IN PLACE <br /> ESTIMATEODATE LABTUSED(YRIMO/DAY) 455 ESTIA QUANTITY OFSUBSTANCE REMAINING 456 FILLED HATH INERT MATERIAL? 457 <br /> v 1-0i <br /> gallons <br /> rYes 1-No <br />