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U NIFI EDP ROG RAM CONSOLIDATEDF O RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (hnro pages per hank) <br /> Page _ of _ <br /> TYPEOFACTION r1. NEWSITE PERMIT r4. AMENDED PERMIT %k5. CHANGE OF INFORMATION) r TEMPORARY SITE CLOSURE <br /> (Check orreltem orgy) r 7. PERMANENTLY CLOSED ON SITE <br /> r3. RENEWALPERMIT (Spedrymason-Mrlocal use orgy) (Spedfychange-forbcafuseonly) r a. TANKREMOVED 430 <br /> BUSINES NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 + '€. <br /> �y„m �- Itix <br /> Pm 1 <br /> LOCATION WITHIN SITE(Opffamo 431 <br /> OESCRIPTIO[rt � �� 0(7he UST syslemltldu+Sfngbwldm§s 2nd7andmarks shau be submrHed,b the local agency) <br /> -T O->r43 <br /> ._.. -.-.. <br /> 2 XN - R _/11, 433 COMPARTMENTALIZED TANK r Yes o 434 <br /> 1 - j f MAYesz,complete one page Por each comparMeM. <br /> DATE INSTALLED(YEARIMO) 435 TANK CAPACITY INS+ALLON\S/ 436 NUMBER OF.COMPARTMENTS I 437 <br /> ADDITIONAL DOCRIPTIOR71almllcal use orgy) 439 �Z <br /> ��_�� ����JJJJJ - TANK USE 439 PETROLEUM TYPE <� <br /> �M 11. MOTOR VEHICLE FU EL r1a. REGULARUNLEADED r2. LEADED r5. JET FUEL <br /> fTmadreQ cosnplele Pebobvm Type) 1b. PREMIUM UNLEADED 1-3. DIESEL r 6. AVIATION FUEL <br /> r2. MON-FUEL PETROLEUM a MIDGRADE UNLEADED 1-4. GASOHOL r99. OTHER <br /> r 3. CHEMICAL PRODUCT COMMON NAME prom Hazanlous Matedeh Inventory page) 441 CAS k(knm HalaldOas Mafeda/s Inventory page) 442 <br /> r 4. HAZARDOUS WWSTE(Includes <br /> Used Din <br /> 1-95. UNKNOV44 <br /> TANK CONSTRIf gong" s "r .f4`yrss.r 5x <br /> TYPE OF TANK ]'1. SINGLE W0.L r 3. SINGLE NULLWTH r 5. SINGLE WALL WTH INTERNAL BLADDER SYSTEM 443 <br /> (Check one item a*) K2 DOUBLE WILL EXTERIOR MEMBRANE LINER r95. UNKNOWN <br /> r 4. SINGLE WLLL INA VAULT <br /> 1-99. OTHER ab <br /> TANKMATERUL-Pnarylsnk r 1. BARE STEEL V4 FIBERGLASS/PLASTIC r S CONCRETE r95. UNKNOWN 444 <br /> ,check ovreilem only) r STAINLESS STEEL r4 STEEL CLAD WFIBERGLASS rB. FRPC0MPATIBLEW1W%METHANOL 1-99. OTHER <br /> REINFORCEDPLASTIC <br /> FRP <br /> 'ANK MATERIAL-secondary 1-1. BARE STEEL v.1 FIBERGLASS/PLASTIC B. FRP COMPATIBLE mom METHANOL 1-95. UNKNOWN 445 <br /> ank <br /> T'2 STAINLESS STEEL r 4. STEEL CLAD r 9. FRP NON CORRODIBLE JACKET 1-99. OTHER <br /> Check one item ony9 WFIBERGLASS <br /> REINFORCED PLASTIC r10. COATED STEEL <br /> (FRP) <br /> 1-S. CONCRETE <br /> ANK INTERIOR LINING r 1. RUBBER LINED r3 EPDXY LINING r5. CLASS LINING r95. UNKNOWN446 DATE INSTALLED 447 <br /> IR COATING b <br /> :heck cneilem on r 2 ALKYD LINING r 4 PHENOLIC LINING YA. UNLINED r99. OTHER <br /> Forkxalusa <br /> THEIR CORROSION 1-1. MANUFACTURED r 3. FIBERGIASS REINFORCED PLASTIC r95. UNKNONM 448 DATE INSTALLED <br /> ROTECTION IFAPPLICABLE CATHODIC449 <br /> ;heck one item Only) PROTECTION r4. IMPRESSED CURRENT r99. OTHER M>oNL <br /> r 2 SACRIFICIAL ANODE (Forbeal use only) <br /> PILL AND OVERFILL YEAR INSTALLED TYPE(Fubcal use only)451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> 450 1 <br /> ;heck all thef apply) -�-�/ y� <br /> 1�. SPILL CONTAINMENT��J r I. ALARM til, FILL TUBE SHUT OFF VALVE <br /> /5 � <br /> .rr..++ DROP TUBE r 2. BALL FLOAT r 4. EXEMPT <br /> A-3a STRIKEERPLATE Gti.Jc <br /> IV..TANK LEAK DETECTION (A Jeacop ion pfIlia mo rformgprogram shall besuara4lud fo ME loaf age <br /> IF SINGLE WALL TANK iCbsc?ailflataac!yj453 IEDOUBLE WALL TANK OR TANKWITH BLADDER(Check one Item only)' 454 <br /> � 1, VISUAL(EXPOSED PORTION ONLY) r5. MANUAL TANK GAUGING(MTG) rt. VISUAL(SINGLE WALL INVAULTONLY) <br /> �2 AUTOMATIC TANK GAUGING(ATG) r6. VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING <br /> 3. CONTINUOUS ATG r 7. GROUNDWATER r 3. MANUAL MONITORING <br /> �4. STATISTICAL INVENTORY RECONCILIATION(SIR). r . TANKTESTING <br /> snnr.Tesrry accrlur_ <br /> V TANK CLOSURE INFORMATION PERMANENT CLOSURE IN f? P"TE <br /> ESTIMATED DATE LAST USED(YWMOMAY) 455 ESTI! I QUANTITY OF SUBSTANCE REMAINING 456 \J FILLED WTH INERT MATERIAL? <br /> i <br /> gallons <br /> r Yes 1-No <br />