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WIFTED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (two pages per <br /> Payef <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT [14 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ap-1 <br /> `16(C6ek a.e..m mly) /a 7 PERMANENTLY CLOSED ON SITE �f <br /> ❑ J RENEWALPERMIT (spc Jyru. -Ibrlcjl mly) (sp« ym• -rorb laremly) 3 TANK REMOVED 410 <br /> BUSDMSSN (S=..FACa NA ar DBA-D SBo=M) FACILITY ID: I <br /> T <br /> LOCATION WITHIN SITE(op'.J) <br /> 05 <br /> L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to th local agency.) <br /> TANK q 412 TANK MANUFACTURER 411 COMPARTMENTALIZED TANK ❑Yes o y. <br /> mgW<am page for ort mmp.•m�mr. <br /> DA TALLED YEAR/MO) 415 TANK CAPACITY GALLONS 4J6 NUMBER OF COMPARTMENTS m <br /> ADDITIONAL DESCRIPTION(For loulus mly) 438 <br /> U.TANK CONTENTS ' <br /> TAIJK USE 114 PETROLEUM TY-,E ua <br /> �I. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED [12. LEADED ❑S. JET FUEL <br /> (ju``—• mi..p]..Pmo4,•m Tyre) Ib. PREMIUM UNLEADED ❑J. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME frmm H...r4aa, gL•avlt blmory p.ge) 441 CASN(6am tl.ordm.Mnmi.lg lavomry p.ynl u2 <br /> ❑4. HAZARDOUS WASTE <br /> nnlwnep u.re oa) <br /> 0 9 UNKNOWN <br /> M. TANK CONSTRUCTION <br /> 'TYPEOFTANK O L SINGLE WALL 03. SINGLE WALL WITH [15 SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 <br /> (C6mknneamnmW EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT [199 OTHER <br /> TANK MATERIAL-p—w lm4 Lf I. BARE STEEL J FIBERGLASS/PLASTIC 0 5. CONCRETE El 95 UNKNOWN 444 <br /> (@mk me'mm�mlyl <br /> 02. STAINLESS STEEL ❑4. STEELCLAD W/FIBERGLASS ❑3. FRP COMI'TIBLE WIMATl.METHANOL C1.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-—.d.ry unk L BARE STEEL . FIBERGLASS/PLASTIC 5. CONCRETE C1 95. UNKNOWN 445 <br /> 1@alk me..m miy) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑3. FRI'COMEMBLE W/IOn°:METHANOL Cl 99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1.RUBBER LINED 0 S.EPDXY LINING 5,GLASS LINING 95 UNKNOWN 446 DATE INSTALLED 441 <br /> OR COATING Cl'_ALKYD LINING ❑4 PHENOLIC LININGUNLMEO ❑99 OTHLR <br /> (@Mk mo nom mly) �• -(Far bol aw only) <br /> OTHER CORROSION 0 1 MANUFACTURED CATHODIC ❑7 FIBERGLASS REINFORCED P_ASTIC ❑95 UNKNO!!Tl 44't PATE INSTALLED 44° <br /> I <br /> PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑W OTHER 1 <br /> (O.-k me Dem only) ❑2 SACRIFICIAL ANODE (For bca utt°oNl <br /> SPILL AND OVERFILL YEARINSTALLED 450 TYPEIbulua:only) i5I OVERFILL PROTECTION EQUIPMENT:YEAR INS"GALLED 452 <br /> UI <br /> 1@cck.0 ouuppiyl XI SPILL CONTAINMENT ❑ I ALARM 1FILLTUBE SHUTOFF VALVE <br /> �'_DROP TUBE ❑'_ BALL FLOAT ❑4 -XEMPT <br /> 3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A deamprm.arm.mm my pmynm.nJl4 ab..W tome bo111-11) <br /> IF.SINGLE WALL TANK(chek.a,ha.pply) 4S1 ga IF DOUBLE WALL TANK OR TAMC WITH BLADDER j5' <br /> j@«k one erm mlyl <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 10 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑3 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE IN'FOILSL\TION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/M0/DAY) 415 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK PILLED WITH INERT h1ATERIAL7 <br /> gallons ❑ Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly S W RCB Form B <br />