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t <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 ("pages per tank) <br /> Page_of <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMlT 5.CHANGE OF LV'FOKMAIK3.N O 7.ERANENT CLOSED ON SITE 4� <br /> (Cheek ane nem only) ❑ 3.RENEWAL PERMIT (SP�ib °a) r-3 S.TANK REMOVED <br /> (specify reason) 1. <br /> BUSINESS NAME(Same.FACILI'lY NAME« -ming Bminw As) 3. FACILITY ID: <br /> C,61VI o -vt- G S 93Y <br /> 90 431. <br /> LOCATION WITHIN SITE(Optio aq <br /> 1 I� T- I.TANK DESCRIPTION <br /> (A scaled lot plan with the location of the UST system including buildings and land wics shall be subroitted to the local433. COMPARTMENTALIZE TANK aUYces) No 434. <br /> TANK ID# 432. TANK MANUFACTURER <br /> T5 -1a x-Yei ER OF C P6c ART a ENTScm. <br /> !/ ass. TANK�APACITY IN GALLONS U6_ NUMBER OF COMPARTMENTS u9. <br /> DATE INSTALLED <br /> (YEAR/MO) ® 00 <br /> 43s, <br /> ADDITIONAL DESCRIPTION(Far keel me only) <br /> II.TANK CONTENTS <br /> a4o. <br /> TANK USE 439. PETROLEUM TYPE <br /> Rr1. MOTOR VEHICLE FUEL C]Is. REGULAR UNLEADED 02.,I EADE D ❑5. JET FUEL <br /> (if chake0.cm Vtc P-k.Type) ❑Ib. PREMIUM UNLEADED �3 DIESEL ❑6. AVIATION GAS <br /> [1 2. NON-FUEL PETROLEUM 4. GASOHOL ❑99.OTHER:ElIc. MIDGRADE UNLEADED ❑ �I 942. <br /> [33. CHEMICAL PRODUCE COMMON NAME(ham xavrmm Mazeriala lnventay page) <br /> CAS#IF= Mazeriab]memory page) <br /> ❑ 4. HAZARDOUSWASTE <br /> (Ixludes Uud Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. INGLE W ALL ❑3-S INGLE W ALL WITH EXTERIOR ❑5. SINGLE WALL NITH INTERNAL BLADDER SYSTEM 441 <br /> MEMBRANE LINER ❑95. UNKNOW N <br /> (Check oM item only) 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [199. OTHER <br /> sa4. <br /> TANK MATERIAL-primary tank ❑ I. BARE STEEL �,3 IBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN <br /> ((Teck wee hem only) ❑2. STAINLESS STEEL YG4 STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC FRP W/I00X METILM40L <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. FRP COMPTBLE W/IBMETHANOL 95.UNKNOWN M5. <br /> 09. DABLE JACKET <br /> (Check one item only) [32. STAINLESS STEEL[14. MEL CWIFIBERGLASS <br /> REINFOED PLASTIC(FRP) ❑la.COATED STEEL <br /> ❑99.OTHER <br /> ❑5. CONCRETE I DATE INSTALLED 44I. <br /> 1.RUBBERISSLR 9..UNOWN <br /> _ <br /> TANK INTERIOR LINING 2.ALKYD LINING C)4.PHENOL10 3 EPDXY IC LINING ING Lr&UNLINED�G ❑99.OTHER <br /> OR COATING <br /> Check one item onl <br /> OTHER CORROSION I.MANUFACTURED CATHODIC ❑4.FIBERGLASS <br /> SSED C BURRENTCD PLASTIC ❑ -99-GROWN 44a, DATE INSTALLS 44 . <br /> PROTECTION PROTECTION ❑ <br /> If licable ❑2.SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED 45o. TYPE 451. O PROTECTION EQUIPMENT: YEAR INSTALLED 4 . <br /> ( ' LARM ❑3.FILL TUBE SHUT OFF VALVE <br /> (Check at twt apply) O 21..SPILL CUBE CNT 2.BALL FLOAT_ ❑4.EXEMPT <br /> DROP❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be4536�IFDOUBLE WWto the local ALLLTTANK OR TANK WITH BLADDER q54. <br /> IF SINGLE WALL TANK (Check ow item only) <br /> (Check all <br /> IS that apply) 5 MANUAL TANK GAUGING(MTG) ❑1.V�9UAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) ❑ CONTINUOUS INTERSTITIAL MONITORING <br /> [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE <br /> [13.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONTTOIUNO <br /> (14. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)*BIENNIAL TANK TESTING [3 99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE INPLACE 457 <br /> dss. ESTENATED QUANTITY OF SUBSTANCE RENAMING 4w. TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ❑Yes ❑ No <br /> gallons <br /> Rev.02116/00 <br />