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--------------- EDP ROGRAM CONSOLIDATED FORM f � UNDERGROUND STORAGE TANKS -TANK PAGE I TANKS - - - 0 0 Page S�r tank) Page c! TYPE OF ACTION ❑I.NEN SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSUR= (Check ons Ilam only) 3-RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (spedty reason•tar local use Dory) (speoe/change-tarkrcal use only) ❑ 8. TANK REMOVED 433 BUSINESS NAME(Same as FACILITY NAME ar DELA-Daing Business As) FACILITY IDS a LOCATION W4 IN qa(CPocnaq 431 - 191 0!, �a ).TANK DESCRSPTICN r� TANK 10 A yy - TANK MANUFACTURERCOMPARTMENTAUZED TANK ,�J Yes ❑ Na 4`- C u Cc. If-Yes'.Complete ane page 1cr each comparL,,t /n DATE INSTALLED(YEAr�RIMO) TANK CAPACITY{N GALLONS NUMBER OF COMPARTMENTS 4 CS Q 0 - A110IT4.14AI DESCRIPTION(Far Vocal use onty) 11.TANK CONTENTS -- TANK USE 432 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE_FUEL ❑1a. REGULAR UNLEADED EQ 2. LEADED ❑ 5. JET FUEL (trmarked,completePearo4um Fype) ❑lb. PREMIUM UNLEADED 3. DIESEL ❑ 8.AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRACE UNLEADED Cl 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRCOUCT El 4. HAZARDOUS WASTE 1tnUudes COMMON NAME(6nm Hautdous Matanals In enlceypege) CAS•(!mm Hazardous Malenals i-tarypagO Used Oiq vvN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3..SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one)tam anty) Z OCUBLE WALL EXTERIOR MEMBRANE UNER ❑95. UNKNOWN Cl 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-pnmary Is- S 1 BARE STEEL Cl 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item anty) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS Q 8, FRP COMPATIBLE W1100%METHANOL 0 99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL•setanoa+Y lank Q 1 BARE STEEL 3 FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE VJt100%METHANOL ❑95. UNKNO•AN (Check 0-1-only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CLAD WIPIBERGLASS Cl 9. FRP NCN•CORRODIBLE JACKET [ 99. OTHER REINFORCED PLASTIC(FRP) Cl ta. COATED STEEL ❑ 5, CONCRETE tty9� TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 0 95. UNKNOWN433 'RATE INSTALLED OR COATING Cl 2. ALKYD UNING ❑ 4. PHENOLIC LINING Cl 8. UNUNED ❑99. OTHER (Check one Rem onlyl _ _ _ _ (For local use ony) OTHER CORROSIONDATE INSTALLED PROTECTION IF APPLICABLE © 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ,®45. UNKNOWN 434 PROTECTION ❑ 4. IMPRESSED CURRENT Q 49. OTHER {Check one Ilam anly) ❑ 2. SACRIFICIAL ANCOE (For Mcw use o^ly) ` SPILL AND OVERFILL YEAR INSTALLED TYPE(Forkscatuse only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check as that apply) ID L SPILL CONTAINMENT S%I aJl,, fl GyU� ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE 2, BE---, i C L",7 Z BALL FLOAT 4. EXEMPT ® 3. STRIKER PLATE "'-'?$1 IV. TANK LEAK DETECTIONIF&NGL.E WALL TANK(Check all Mat apply): IF OCU BLE WALL TANK OR TANK WITH BLADDER(Check ane item Dory): ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATEC TANK GAUGING(ATG3 ❑ 8. VAOOSE ICNE 2_ CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MCNITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER _ V.TANK CLOSURE LNFORMA TION I PERMANENT CLOSURE 1N PLACE ESTIMATED DATE LAST USED(YPJMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? I 9a8ons ❑Yes ❑No CUPAFORM(4199) Formerly SVVRCB Form 5