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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Iwo Pages per tank) <br /> Page a- of 3- <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT . CHANGE OF INFORMATION) ❑ 8.TEMPORARY SITE CLOSURE O <br /> (clack.same onry) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Spaoli-an brkxal uaa wyl (Spao/y cearps-brbpal ms only) ❑ S. TANK REMOVED 430. <br /> BUSINESS NAME <br /> E`(Same as FACILITY NAME or DBA-Going Business Aa) FACILITY IO• �* J O, <br /> S+miz aur -t /2$Rq i - 11 g-11 <br /> LOCATION WTHIN SITE Lit <br /> 1.TANK DESCRIPTION <br /> TANKIpe e TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yea No <br /> If-Yef•,mmplNe pM papa fpr aar11 mm a,,., <br /> DATE INSTALLED(YEA"O.) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> W/ �v <br /> ADDITIONAL DESCRIPTION(Ferlocal use a*) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MO TOR VEHICLE FUEL Ala. REGUURUNLEADED 132. LEADED ❑ S. JET FUEL <br /> (1/ ,compw.PahoMum Type) 10 PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8. AVIATIONFUEL <br /> ❑ 2. NON-FUEL PETROLEUM 1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> Cl 4. H RDOUS WASTE(ImiWaa COMMON NAME(how Hazansouf Materials Inventory page) CAS a(hom HaaarEoua Matwlala InvenfoD•page) <br /> Usad D p <br /> 095 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPEOFTANK , SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (OMd on,dem onyj ❑ 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> Cl 4 SINGLE WALL IN A VAULT 1199 OTHER <br /> TANK IMTERIAL-plenary tank 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Cheok.,I..amyl ❑ 2. STAINLESS STEEL ❑4. STEEL CUD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-xrdidary Wk -1 BARE STEEL ❑ 9. FIBERGLASSIPUSTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL 1195. UNKNOWN <br /> (Chxk one dem any) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD WIFIEERGUSS ❑ 9. FRP NONCORRODIBLE JACKET 1199. OTHER <br /> REINFORCED PUSTIC(FRP) 010.COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNMOM433 DATEINSTALLED <br /> OR COATING �/ <br /> (LMpk one dem on ) 11 2.ALKYD LINING ❑ 4. PHENOLIC LINING Aa B. UNLINED ❑99. OTHER <br /> OTHER f (FwbcL we <br /> PROTECTION <br /> IF ON 11 1 MANUFACTURED CATHODIC ❑ 3. FIBERGUSS REINFORCED PLASTIC UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION 0 A IMPRESSED CURRENT ❑99. OTHER <br /> (DMckoM ihm army) ❑ 2. SACRIFICIAL ANODE (Fwbcal use pnyJ <br /> SPILLANOOVERFILL � Sf y INST LED TYPE(ForboaluaeoMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> o �41 <br /> (GMCkYwat appyq 0 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUSE ❑ 2. BALL FLOAT Cl 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK haer aaf l• IF DOUBLE WALL TANK OR TANK WITH BLADDER(Ch one ismo ): <br /> ❑ 1. VISUAL(EXPOSEDPORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUSINTERSTITIALMONITORING <br /> ❑3. CONTINUOIISATG ❑ T. GROUNDWATER Cl 3. MANUAL MONITORING <br /> ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR). ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING .a5L��I/99. OTHER /V Gr/{,y21 <br /> .Li <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRRJMGIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLEDWITH INERT MATERIAL? <br /> lir O V ealbna <br /> ❑Y )JQFb <br /> CUPAFORM(4/99) Formerly SVVRCB Form B <br />