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AIFIED PROGRAM CONSOLIDATED FOIr'. <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Ab Pages pe,Mnk) �I <br /> ��y -rh05I5S'TI Page _ el <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT `�J S. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Chock om Kem Dory) X\ ❑ T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (Speriynlason lwkcNvsemly) (Spx+y change-/erlocN use only) 0 S. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA.DNng Business M) FACILITY ID R t <br /> 1�R/+ R D Vzh f t& res <br /> LOCATION WITHIN SITE <br /> �- <br /> I.TANK DESCRIPTION <br /> TANK ID is TANK MANUFACTURER <br /> .10 B COMPARTMENTALIZED TANK ❑ Vee a <br /> �^�+ It'Yaa',complNs aria pegs for saN mmPaNnent. <br /> DATE INSTALLED(YEARpl07 TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Fwkcal use oW <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED X2. LEADED 0 5. JET FUEL <br /> (Ila,aMml...pleh PegNeua,Type) lb PREMIUM UNLEADED 0 3, DIESEL D B. AVIATION FUEL <br /> 0 2. NDN-FUEL PETROLEUM ❑lc MIDGRADE UNLEADED 0 4. GASOHOL 099. OTHER <br /> 0 3. CHEMICALPRODUCT <br /> ❑ 4. HAIARCOUS WASTE(InclWes COMMON NAME <br /> NaiaNpua Mata/ials/menforypege/ DABa(xmm Naxattlove WNriala lnwnfwypage) <br /> UsW DY) <br /> 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ljFr_ SINGLEWALL 11 3. SINGLEWALLWTH 0 5, SINGLE WALL NTH INTERNAL BLADDER SYSTEM <br /> (Chock.sea,ahoy) 0 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> -❑ 4. SINGLE WALL IN A VAULT 0 99. OTHER <br /> TANK MATERIAL-primary tank X,. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC 06. CONCRETE 095. UNKNOWN <br /> (Chock mw ilea,any) D 2, STAINLESS STEEL ❑4. STEELCLADWIFIBERGUSS 0 8. FRP COMPATIBLE W/lW%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-eemnaary tank 0 1 SARE STEEL ❑ 3. FIBERGLASSIPLASTIC 08 FRP COMPATIBLE NII%METHANOL 095. UNKNOWN <br /> (Check mw Bem onW D 2. STAINLESS STEEL 0 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS LINING 095. UNKNOWM433 DATE INSTALLED <br /> OR COATING Yp�� <br /> 112.ALKYD LINING 0 4. PHENOLIC LINING I 1A. UNLINED 1199. OTHER (Fwwalusaw <br /> Cpeck one iNm oN <br /> lA <br /> OTHER CORROSION 0 1 MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC WAS. UNKNOWN 4 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION �`I�yy <br /> 04. IMPRESSED CURRENT y�99. OTHERAA9l_e(w2 (Fsrclua..,N <br /> (Chock Dna".ahoy) ❑ 2. SACRIFICIAL ANODE e` <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwkralusaony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chock am lMbpply) D 1 SPILL CONTAINMENT 0 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE ❑ 2. BALL FLOAT 0 4. EXEMPT <br /> D 3. STRIKERPLATE <br /> N.TRNK LEAK DETECTION <br /> IF SINGLE WALL TANK hock atl thele IF DOUBLE WALL TANK OR TANK WITH BUDDER eck ens item pN): <br /> 01, VISUAL(EXPOSEOPORTION ONLY) 05. MANUAL TANK GAUGING(MTG) 01. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> Cl 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSE20NE 0 2, CONTINUOUS INTERSTITIAL MONITORING ' <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER 0 3, MANUALMONITORING <br /> 0 4. STATISTICALINVENTORV RECONCILIATION(SIR) 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING 99_ OTHER -m 611 x <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YIUMOi/ Y) ESTIMATED QUANTITY OF SUBSTAN EREMAINING 435 ETANK FILLED NTHINER�MATERIAL? <br /> gallons <br /> MAR 2 $ Z001 <br /> ENVIRONS PNTHEALTH FormerlySWRCBFOnnB <br /> CLIPAFORM(4/99) PERM*mOERVICES <br />