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IFIEO PROGRAM (CONSOLIDATED Fo <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> I <br /> k 0wo Rages pev rank) <br /> Page _ at _ <br /> TYPE OF ACTION ❑1.NEN SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE CF INFORMATION) ❑ 6. TEMPCRARY SITE CLCSURE <br /> (Check one item Only) I1TTS� ❑ 7. PERMANENTLY CLOSED ON SITE <br /> �r.•.1 3.RENEWAL PERMIT (Spech�„mason.rarfOcal use Only) (spoor r ehenge-P_rlocal use Only) 8. TANK REMCVEO 410 <br /> BUSINESS NAME(Same as FACILITY NAME or D8A-Ocing Business All FACILITY <br /> rG \ C( <br /> LOCATION VATHIN SITE MO=arj 431 S1 <br /> S [1 v� <br /> L TANK DESCRIPTION <br /> YANK 10 t TANK MANUFACTURER CCMPARTMENTALZED TANK 'fes ❑ Na <br /> 1J I.uGl If Ycam <br /> es',complete ane page(er ea= par>;nane <br /> ` G <br /> GATE INSTALLED(YEAPIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> We co x VV 00 o i <br /> ADOLTIOMALDESCRIPTION(Far lata!use aNy) <br /> IL TANK CONTENTS <br /> TANK USE 412 PETROLEUM TYPE <br /> ty�1. MOTOR VEHICLE FUEL 1a, REGULAR UNLEADED ❑ 2. LEAOEO - ❑ Is. .iET FUEL <br /> (U marked,campiete Petreie.m Type) ❑10 PREMIUM UNLEAGEO ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NCN-FUEL PETROLEUM ❑1c MIOGRADE UNLEADED ❑ d. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PROOUCT - <br /> COMMON NAME(Ilam Hazardous Materiatz In-10,Y page) CAS t(Imm Haza,daus Materials im ntary page) <br /> C1 4, HAZARDOUS WASTE(frrcJudds <br /> Used Oi,7 i. <br /> N <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL ❑ 3_.SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLACDER SYSTEM <br /> {Chock ane dem Only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 0 95 UNKNOWN - <br /> ❑ 4. SINGLE WALL IN A VAULT 0 99 OTHER <br /> TANK MATERIAL.9-wy tank Ipl- 1 BARE STEEL ❑ 3. FIBERGLASS t PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check ane dem only} �❑+ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFISERGLASS ❑ 5. FRP CCMPATIBLE WI100%METHANOL ❑99. OTHER _ <br /> R EINFC:RCEC PLASTIC(FRP) <br /> TANK MATERIAL•se[andary Lank ❑ 1. BARE STEEL 1 FIBERGLASS t'PLASTIC ❑ 8. FRP COMPATIBLE Wf100%METHANOL Cl 95. UNKNOWN <br /> (Check One itern aMyy ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFlBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKS ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING X 45. UNKNOWN433 D'O'TE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ <- PHENOLIC LINING ❑ 8. UNLINED ❑94. OTHER <br /> (Check Ona item anH) (Forlocal use anh/) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1R95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICASLE PROTECTION <br /> 4. IMPRESSED CURRENT ❑49. OTHER <br /> (Chock and item only) [] 2. SACRIFICIAL ANODE (Far lata,ua.aHyl - <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(FcrYacad use Only} OVERFILL PROTECTION EOLAPMENT:YEAR INSTALLED <br /> (Ch.c.k aL(hal appy) .1SPILL CONTAINMENT 1�'L f'1 I✓tvs.±-`'I' � Cl 1. ALARM <br /> CI 3. FILL TUBE SHUT CFF VAL`!c <br /> t4u 2 DROP TUBE ( (H 2. BALL FLOAT Cl 4. EXEMPT <br /> L;I 1. STRIKER PLATE <br /> IV. TANK LEAK DETECTION - - <br /> IF SINGLE WALL TANK(Check ail that apply): IF OCUBLE WALL TANK OR TANK WITH BLACOER!Check ane ilea-Aryl: <br /> ❑ 1, VISUAL JEXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL{SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑3 S. VADCSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 03. CONTINUOUS ATG - 0 7. GROUNV.VATER ❑ 1, MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑9g OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE]N PLACE I <br /> ESTIMATED OATS LAST USED(YRIMCIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINIYG 435 TANK FILLEDWITH INERT MATERIAL? <br /> gailcns <br /> ❑Yes No <br /> CIJPAFORM(4199) Fcrrrierly SWRCS Fc,ro 6 <br />