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mc, (0\ <br /> �\o-\ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Bw Pages per bnNJ <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ a.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Ch.k..R.mg.y) ❑ T. PERMANENTLY CLOSED ON SITE <br /> RENEWAL PERMIT (]parity naaw-brba vta only) (SpaCky clangs-brlxL ms only) ❑ S. TANK REMOVED 430 <br /> BUSINESS NAME(Same v FACILITY NAME or DBA-Oging Business At) FACILITY ID a 1 <br /> lip OD0�59 TA050�v7 <br /> LOCATION NATHIN SITE(Opa:na 1 <br /> 141 e16c tX!*�m� (/FNwp8MAF �t5z y a <br /> 1.TAAKDESCRIP770N <br /> TANK 100 TANK MANUFACTURER COMPARTMENTAUZEOTANK ce* s ❑ eN. <br /> n <br /> 30--2- <br /> 2- TMJ �/ It complete one page Ice aaUl wmpaRment. <br /> DATE INSTALLED TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> qS S (0000 Z <br /> AOOITIO LDESCRIP ION -g ✓Ny, •�� ') <br /> '//-��]1\ II.TANKCONTENTS <br /> TANKUSE 432 PETROLEUM TYPE <br /> XMOTOR VEHICLE FUEL ❑(��1a REGULAR UNLEADED ❑ 2. LEADED 115. JET FUEL <br /> (Ilmaded,complete PMmlaum Type) Alb. PREMIUM UNLEADED ❑ ]. DIESEL ❑ B.AVIATIONFUEL <br /> ❑2. NON-FUEL PETROL'_UM ❑Is. MIOGRADE UNLEADED ❑ A. GASOHOL ❑99. OTHER <br /> ❑ ]. CHEMICAL PRODUCT COMMON NAME I".H..Moua NaloNfa lnvanlorypags) CASe(agm H.aanl.Yt Mabdala lmantg...... <br /> ❑ a. HAZARDOUS WASTE(Include. <br /> Uxad Oa <br /> rl 95 <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLEWALL ❑ ]. SINGLEWALLWITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> ./2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check ane aam a*) A '❑ a SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-pdmAry tank TEEL 11 <br /> 3 FIBERGLASS/PLASTIC ❑ 5. CONCRETE 0 9. UNKNOWN <br /> (Chock wn item way) ❑ 2. STAINLESS STEEL 05L STEEL CUD WIFIBERGUSS ❑ B. FRP COMPATIBLEWIIW%METHANOL 0 9. OTHER <br /> J REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-sewoc.q Mnk TEE L rJLoTFi(Z. eI PLASTIC ❑ B. FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (Chackgnakemwty) ❑ 2. STAINLESS STEEL STEEL CLAD WIFI8ERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 1199,OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5 CONCRETE <br /> DATEINSTALLEO <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING GLASS LINING ❑95. UNKNOWNI]] <br /> OR COATING <br /> ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 5 UNLINED 99. OTHER Forlwal uxeo ) <br /> (CMck one aem gall DATE INSTALLED <br /> OTHER CORR090N t. MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOVM A]I <br /> PROTECTION IF APPUCA3 E PROTECTION <br /> 0. IMPRESSED CURRENT 1199. OTHE0. (Fwbca/uaa only) <br /> (Chock one item way) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL IA F�y YEAR INSTALLED TYPE(Forbcafuta`mw <br /> OVERS PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chock as that appy) 1 SPILL CONTAINMENT ALARM __ ❑ 1 FILL TUBE SHUT OFF VALVE <br /> ❑ 2. OROPTUSE 2. BALL FLOAT_ ❑ A. EXEMPT <br /> ❑ ]. STRIKER PLATE <br /> N.TANK LEAK DETECTION ' <br /> IFOOUBLEWALLTANKORTANKWITHBLADOERMINKAOneifem an ): <br /> IF SINGLE WALL TANK all Mat AP ): <br /> ❑ 1, VISUAL(EXPO-SED PORTION ONLY) ❑ S. MANUALTANKGAUGING(MTC) ❑ � VISUAL(SINGLEWALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 2 CONTINUOUS INTERSTIT9AL MONITORING <br /> ❑ 0. CONTINUOUSATG ❑ ?. GROUNONATER ❑ ]. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 0 OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING A]5 TANK FILLED WITH INERT MATERIAL? <br /> Sell... ❑Yes ❑N. <br /> Formedy SVVRCS Farm B <br /> CUPAFORM(4199) <br />