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Owner Namefrom Section) CGe <br />( ) ZIQ/' �.._f-Location (!rem Sucidcn i1� <br />�•� r� <br />� <br />ran <br />Tank Identification No. (e.,AABC-123),t,00 <br />Arbitrarily Assigned Sequential Number (P.g.,1,2,3...) <br />I <br />Py1pN' <br />Tai % o. <br />Tank No. <br />- <br />, <br />1. Status of Tank <br />(Mark allthatapply ®) Currently in Use <br />� <br />Temporarily Out of Use <br />O <br />Permanently Out of Use <br />0 <br />�� <br />Brought into Use after 5/8/86 <br />2. Estimated A e (Years) <br />3. Estimated Total Capacit Getlona <br />4. Material of Construction Steel <br />(Mark one Z) <br />® <br />® <br />Concrete <br />O <br />Fiberglass Reinforced Plastic <br />Unknown <br />Other, Please Specify <br />5. Internal Protection <br />(Mark all that apply J Cathodic Protection <br />0 <br />0 <br />nterior Lining (e.g., epoxy resins) <br />0 <br />None <br />O <br />O <br />Unknown <br />Other, Please Specify <br />6. External Protection Cathodic Protection <br />(Mark all that apply ®) <br />Painted (e.g., asphaltic) <br />Fiberglass Reinforced Plastic Coated <br />17-171 <br />u <br />None <br />0 <br />Unknown <br />Other, Please Specify <br />7. Piping Bare Steel <br />(Mark all that apply ®) <br />® <br />0 <br />Galvanized Steel <br />Fiberglass Reinforced Plastic <br />[�O <br />g <br />0 <br />Cathodically Protected <br />O <br />Unknown <br />0 <br />0 <br />0 <br />O <br />Other, Please Specify <br />8. Substance Currently or Last Stored a. Em pty <br />in Greatest Quantity by Volurne <br />O <br />O <br />�, <br />II <br />bpetroleum <br />(Mark all that apply®) . <br />Diesel <br />0 <br />0 <br />C— <br />Kerosene <br />Gasoline (including alcohol blends) <br />Used Oil <br />O <br />O <br />� <br />O <br />Oftf, Please Specify <br />E: bd%A7tfeus Substance <br />Q <br />[ <br />0 <br />0 <br />C7 <br />Please Indicate llfi ie 8f PNnclpal CEFItLA Substance <br />6iiiin ibili Abisitd&i 9etvica (CAS)No. <br />Mark boir t] if 124 sibr@s A Ribiture of substahce5 <br />O <br />-- d, Unknown <br />L i <br />9. Additional Information (Ilortanks permanently <br />taken out of service) <br />a. Estimated date last used (mo/yr) <br />b. Estimated quantity of substance remaining (gal.) <br />c. Mark box ® if tank was filled with inert material <br />- <br />– — <br />(e.g., sand, concrete) <br />4F61444396-ilii'-II81pevetse-- <br />Page 2 <br />