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UNIFIED P ROG RAM CONSOLIDATED FORM :TANK]S , <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> I <br /> Page _ of <br /> ❑ B. TEMPORARY SITE CLOSURE <br /> ttPE OF ACTION ❑1 NEW SITE PERMIT ❑ A. AMENDED PERMIT ❑ 5.CHANGE Of INFORMATION) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (Greco ane item only) <br /> RENEWAL PE0.MIT (5�;,y naaan-brloaluse wy) (Spacd/Nen9s-brlaalun Dory) ❑ B. TANK REMOVED a]0 <br /> 1 <br /> TNAFACWttIOa <br /> BUSINESS NAME(Same as FACILITY ME or DSA-DON9 Buamu+AN oo� , <br /> O59y <br /> LOCATION WITHIN SITE(OPEenag IA]t <br /> lilt Eo'6S k_mLDN`,+"J 640--s' Wal F `� <br /> L TANK DESCRIPTION <br /> TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yu Na <br /> TANK 109 � II•Yo-,cemple[e ane pate kr euA wmpar-men[ <br /> ITANKCAP 5-,61 INllONS NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(Y5ARMO) �1I' <br /> Q3 (Z 00D <br /> AOOITIONALOSS' ION(Farlac I use any) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JETFUEL <br /> REGULAR UNLEADED <br /> to ❑2.LEADED <br /> 1. MOTOR VEHICLEFUEL ❑ 0. DIESEL ❑ B. AVIATION FUEL <br /> (II maM1W,complete PetmNwa Type) ❑ta PREMIUM UNLEADED [199, OTHER <br /> ❑ 2. NON FUEL PETROLEUM ❑1a MIDGRAOEUNLEAOEO ❑ A.GASOHOL <br /> ❑ ]. CHEMIGLPROOUCTGS a ISPm KuarCaua Matenalt lrnanmry page) <br /> COMMON NAME(hpm Haaatlam MalenL+Inwnlorypage) <br /> ❑ A. HAZARDOUS WASTE fImIutlea <br /> USW GO <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I SINGLE WALL [1 ]. SINGLE WALLWTH ❑ 5. SINGLE WALL WITH INTERNAL BLADOER,SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Cnec4arademanry) VOOUBLEWALL '❑ A SINGLE WALL IN A VAULT 099. OTHER <br /> TANK MATERIAL•plimary Mn4 ❑ ]. F19ERGLA55I PLASTIC ❑ 5. CONCRETE <br /> ❑95. UNKNDYAV <br /> lle� <br /> (Cne<4 ane ifam pM/) ❑ 2. STAINLESS STEEL S�STEEL CLAD WIFIBERGUSS ❑ e. FRP COMPATIBLE W100%METHANOL ❑99. OTHER <br /> REINFORCEO PLASTIC IFR P) <br /> TANK MATERIAL-feae"ary tank ❑ ] FIBERGLASS/PLASTIC ❑ 5 FRP CDMPATIBLE W1100%METWINOL 095. UNKNOWN <br /> (Cne<4 ane item anry) ❑ 2. STAMLESSSTEEL Nle STEELCLAOWIFISERGUSS ❑9. FRP NONGORROOISLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATED STEEL <br /> ❑ 5 CONCRETE DATEINSTALLED <br /> TANK INTERIOR LININGLINED ❑ 9 EPDXY LINING C] GLASS LINING ❑95. UNKNOWNA]] <br /> OR COATING ❑ 1. RUBBER LINING <br /> ❑ t. PHENOLIC LINING 6. UNLINED ❑99.OTHER OATEGal u+e LE) <br /> ❑ 2.ALKYD LINING DATEINSTALLED <br /> (CrIK40rNI ROT On ) Au <br /> OTHER CORROSION 1. MANUFACTURED CATHODIC ❑ ]. FlBERGLA55 REINFORCED PLASTIC 95. UNKNOWN <br /> PROTECTION 11 PP CABLE PROTECTION ❑ A. IMPRESSED CURRENT 099.OTHER (Forhrcal use only) <br /> (CAec4 ane iHm aHyl ❑ 2 SACRIFICIALANOOE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLEO <br /> SPILL ANOOVE0.FILL I�pQ YEARINSTALLED TYPE I...*) <br /> (Grea4OV RF !00 I LI,RM __ ❑ ]. FILL TUBE SHUT OFF VALVE <br /> 1. SPILL CONTAINMENT tl-C/ <br /> ❑ 2. DROPTUBE 2. BALL FLOAT__ ❑ L EXEMPT <br /> ❑ ]. STRIKER PLATE -��- <br /> N.TAN KLEAKDETECTION <br /> IF DOUBLE WALL TANK 00.TANK YIITM BLADDER(Groc4 ane Rem onNl� <br /> IF SINGLE WALL TANK all mal ap 1' ❑ - WSUAL(SINGLE WALL IN VAULT ONLY) <br /> O S. MANUAL TANK GAUGING(MTG) <br /> ❑ 1. VISUAL(E%POSEO PORTION ONLY] 2 COKTINUOUS INTERSTITIAL MONIT00.1NG <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSE ZONE <br /> ❑ ]. CONTINUOUS ATG <br /> El 7. GROUNUNATER ❑ x MANUAL MONRORING <br /> ❑ A. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ a. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER,��� <br /> V.TANK CLOSU RE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED( WKWIP ) <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> A]5 TANK FILLED WITH INERT MATERIAL'! <br /> -pagan+ ❑Yea ❑Np <br /> Forme4 SWRCS FDlfn <br /> 1PAFORM(41991 <br />