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�3 IFIED PROGRAM CONSOLIDATED FORrji ANK: PR#: UNDERGROUND STORAGE TANKS -TANK PAGE 1 D AC#: (two pages per tank) Page 2 of 3 TYPE OF ACTION ❑ INEW SITE PERMIT ❑ 4AMIiND[D PFR\11T ❑ SCIIANGF,OF INFORMATION ❑ 6TEMPORARY SITE CLOSURE (Chink`�ly'w1 O1Jy) ❑ 7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT 'SP ty ren« 1«i `Imeonlyl isp:'n ninon-I 1 al vse m0yi TANK REMOVED 430 ln, � BUSINESS (S wFACLHYNAMEm'D/EA-DoingllwesAs) FACILITYID: PR I LOCATION WITHIN SITE( 'map 431 PHONE I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) ETN TANK IDN 432 TANK MANUFACTURER / 433 COMPARTMENTALIZED TANK EJ o 434 i567 If'Ter".wryletemepapfmcechmryemmms. DATE INSTALL D(YEA/MO) 435TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4J7 3a ADDITIONAL DESCRIPTION TF ko I ase Dray) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ I.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.IET FUEL Bfmrkenm 1deP.I.Typc) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL �❑t r96.AVIATIONFUEL ❑ 2.NON-FUEL PETROLEUM ❑ le MIDGRADE UNLEADED E] b 4.GASOHOL .OTHER ❑ 3.CHEMICAL PRODUCT COMMON+NAME(6om Hsffidaas Mucna6 hrvmaypage) 441 CAS#(6om Hamedmas Matena6 levmory page) 443 ❑4.HAZARDOUS WASTE � (maumusedoip 4� . ' I 91-95 UNKNOWN w!/` ID.TANK CONSTRUCTION TYPE OF TANK 2<SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM a3 (CMdconetonoey) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT El99.OTHER TANK MATERW.-yn-i ry reek E I.DOBARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑ 95.UNKNOWN M4 (Ch neitmoely) ❑2.STAINLESS STEEL ❑ STEEL CLAD WNIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(1") ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN M5 (fhbmcitmmy) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ lo.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE �� TANK INTERIOR LINING E] I.RUBBER LINED ❑ 3.EPDXY LINING El S.GLASS LINING 4wf UNKNOWN 446 DATE INSTALLED u7 OR COATING 7 (Chep me itmmly) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑ 6 UNLINED ❑ ".OTHER � (Perloed..mly) OTHER CORROSION E-1I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC rU�r5 UNKNOWN 449 DATE INSTALLED "9 PROTECTION IF APPLICABLE PROTECTION (aeloncismmly) ❑ 2SACRIFICW.ANODE ❑4 IMPRESSED CURRENT El99 OTHER (F«bd use mly) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(lval.eely) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (U«kalldutapply) ❑ I SPILL CONTAINMENT ❑ IALARM ❑ 3 PILL TUBE SHUT OFf(VPI.` ❑ 2 DROP TUBE ❑ 2 BALL ❑4 EXEMPT ❑ 3 STRIKER PLATE FLOAT TV.TANK LEAK DETECTION(Ad.6ptim ofste Imnitohs ptogmnshsll be subnitud mthem aamry.) IF SINGLE WALL TANK(Cheek ell w,appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG). (�c`k omttmmy) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTBRIOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCIIJATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR) 0y )BIENNIAL TANK TESTING 99 OTHER AvkR/ V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) � 455 ESTIMATEDQUANTITY OF SUBSTANCE REMAINING 451 TANK FILLED WITH INERT MATSPIAL? 457 ❑Yes No UPCF(12/99 revised)