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�. 09/29/2005 10:57 2094683433 EHD PAGE 17 LTNIFTED PROGRAM CONSOLIDATED FORM TANKS yya) Qa� t UNDERGROUND STORAGE WANKS- TANTS PAGE X � (Two pages per tank) Page_OF_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 0 S.CRANGE OF INFORMATION ❑ 6-TEMPORARY TANK CLOSURE 430. (Check one hen only) ❑ 3.RENEWAL PERMIT __ ❑ 7.PERMANENTLY CLOSED ON SITE (Speciryremon) (Specitysmann) ❑ 8.TANK REMOVED BUSINESS NAM$(Snore as FACILITY NAME or OSA-Doing Bualnm M) 3. 1 FACILITY ID: k;; ,-0 1, LOCATION WITF@I SITE(Optimal) 431. I . . `T.moi' ,;K-DESCRIPTiQN-' - ...• ... ... A scnled; tot..,an with the loeatioarof the.U sy ei6i :io'cludin bu' snd'landmarks shall be submitted to tlae TANK H) L/?T 437 TANK MANUFACTURER 433. mem1uAA 7v l J�n�� COMPARTMENTALIZED ❑Yes No qa4. M_` )l 1� ompleie one poge for each Soow;atmcaL DATE INSTALLED 435. TANK CAPACITY IN GALLONS 43a NUMBER OF COMPARTMENTS (YtAR/MO) 437. IgCl AA,usT 12, 000 ADDITIONAL DESCRIPTION(ru kw we only) 43a. F. . II:T-ANK*CONTENTS }T�A(NK USE 499. PETROLEUM TYPE J°� I.MOTOR VEHICLE FUEL [Ila, REGULAR UNLEADED ❑2. LEADED ❑5,JET FUEL aao Ofchecked,Mmplete Pe"Itum Typo) ;9 lb. PREMIUM UNLEADED ❑3, DIESEL ❑6.AVIATION OAS ❑ 2. NON•FUEL PETROLEUM ❑le, MIDGRADE UNLEADED ❑4, GASOHOL ❑99,OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(&om Hamrdous Matmiab Iavmtmypage) 441. CAS#(froth Haaand=Materials Inventory page) 442. ❑ 4. HA7_ARDOUS WASTE (IncWts Used OiA ❑ 95,UNKNOWN IIL;'��1,N�•C4NSTRUCTfON - TYPE OF TANK0 1.SINGLE WALL 12 3, SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH[NTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑9S. UNKNOWN 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-priMVy tank 1. BAR],_STE4 3,FIBERGLASS/PLASTIC 1:15. CONCRETE ❑95-UNKNOWN 444 (Check one item only) ❑2, STAINLESS STEEL [14, STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTFmR: _ REINFORCED PLASTIC W/1 Wla METH AN OL TANK MATERIAL-secondary=k Q I. DARE STEEL . FIBERGLASS/PLASTIC [I$. FRP COMPTIHLE W/100^/MP-THANOL 95.UNKNOWN 445. (Check one item only) [12. STAMLESS STEEL❑4. STEEL CLAD WNMERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10, COATED STEEL 5,CONCRETE TANK INTERIOR LINING ❑I,RUBBERLINED ❑3,EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447, OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTI4ER Check one item only) OTHERCORROSION 1,MANUFACC(JRBD CATHODIC Q 3.FrgERGLASS RFLVFDRC);p PLASTIC 95.UNI4ti OWN q4g. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPMSED CURRENT ❑99.OTHER fApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARININSTALLED 450• TYPE 43:. OVERFILLPROTECTION EQUIPMENT, YEAR INSTALLED 452. (Chetk all tlsat apply) 91.SPILL CONTAINMENT �� &I.ALARM U2.DROP TUBE _�(j b 1` �'2.BALL FLOAT_ ❑3,FILL TUBE SI•IUT OFF VALVE_ E34.ID(EMPT 3.STRIKER PLATT; I-V •TA1rIK LI'rAK DETECTION (A description of the monitoiin rogrnm sball,be submitted to rhd local a enc ,) IF SINGLE WALL TANK 4$3• IF DOUBLE WALL TANK OR TANK WITH BLADDER 4s4. (Check all that apply) (Check ow item only) C]I.VISUAL(EXPOSED PORTION ONLY) 115.MANUAL TANK GAUGING(MTO) 111,VISUAL(SING L E WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 3(2>CONTINUOUS INTERSTITIAL MONITORING ❑3,CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4.STATISTICAL rNVENTORY RECONCILIATION ❑S.TANKTE5TING (SIR)+IMUNNIAL TANK TE$TrNG 0 99.OTTER V.TANK CLOSURE INFORMATION/ PERMANENT'CLO SURE IN PI:,AC£ ESTIMATED DATE LAST USED(YWC rDAY) 439, ESTIMATED QUANTITY OF SUBSTANCE REMAIc TING 4M TANK FILLED WITH INERT MATERIAL? � gallons 0 YeN ❑ No UPC}hwfwre-b(1/99),1/4 http:/Avww.uuidocs orR Rev.02/[6100