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NIFIED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Mn pages per lank) <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT- ❑ 4.AMENDED PERMIT .CHANGE OF INFORMATION) ❑ 8.TEMPORARY SITE CLOSURE <br /> (Check oro gam only) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SpecMy neaon-Iorbaluw aMl? (Spec9y change-fie,local uae only) ❑ B.TANK REMOVED 430 <br /> BUSINESS RAMELSamen FACILITY NAME of DBA-Doug BwNeaa As) FACILITY ID N' 1 <br /> ice( 'fCv �►I -� <br /> LOCATION VATHIN SITE(Op9one3 431 <br /> I.TANK DESCRIPTION <br /> TANKIDM / GS/ <br /> TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> II'Yea,complete one papa for each campanmanl <br /> GATE INSTALLED(YEAP/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 10 v <br /> ADDITIONAL DESCRIPTION(Farbcal uae a*) ' <br /> II.TANK CONTENTS <br /> ,.( TANK USE - 432 PETROLEUM TYPE ❑ 5.JET FUEL <br /> .fLl T�MOTOR VEHICLE FUEL Pe". REGULAR UNLEADED 112. LEADED <br /> (Il-led,comPlele Peholeum Type) El ID. PREMIUMUNLEADED - ❑ 3. DIESEL ❑ 5.AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM [3 le, MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99.OTHER <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(fmm Heaardnus MAMAM13 lnwatorype9e) CAB 0(hom HWOM-od Msfedala/nwnfaW Page) <br /> ❑ 4. HAZARDOUS WASTE(/mfudea <br /> Used Die <br /> ITL.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLEWALL ❑ 3. SINGLEWALLVATH ❑ 5. SINGLE WALLWITH INTERNAL BLADDER SYSTEM <br /> 4a <br /> � EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one Item only) t TDOUBLE WALL El 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-Primary tank .[] 1. BARE STEEL FIBERGLASS/PLASTIC ❑ 5.CONCRETE 095. UNKNOWN <br /> (Check ormilam only) ❑ 2. STAINLESS STEEL p0 4. STEEL <br /> EDP <br /> CLAD <br /> WIFIBERGLTIC ASS <br /> -a0 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> TANK MATERIALeconwaryyy <br /> tank 0 1. BARE STEEL vIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL 13 95. UNKNOWN <br /> (Check one Rem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NOWCORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) [110. COATED STEEL <br /> 5.CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ ]. EPDXY LINING ❑ 5. GU55 LINING 095. UNKNOWN433 <br /> DATEINSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ B. UNLINED ❑0.OTHER For local used <br /> (Check oro".02M DATEINSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC (395, UNKNOWN 434 <br /> PROTECTION IF APPUCABLE PROTECTION , <br /> ❑ d. IMPRESSED CURRENT 099.OTHER (Farbeal use only) <br /> (Checkomflemonly) ❑ 2. SACRIFICIAL ANODE <br /> SPILLANOOVERFILL YEAR INSTALLED TYPE(ForMcaluxoaly) OVERFILL PROTECTION EQUIPMENT'YEAR INSTALLED <br /> (Ghecke91hatepplY/ SPILLCONTAINMENT ❑ 1. ALARM FILL TUBE SHUT OFF VALVE <br /> // OP TUBE El 2. BALL FLOAT 0 4. EXEMPT <br /> :/ STRIKER PLATE <br /> N:TANK LEAK DETECTION:" <br /> IF DOUBLE WALL TANK OR TANN WITH BLADDER Check ora item onl <br /> IF SINGLE WALL TANK Check ell Mafa <br /> ❑ 1, W SUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ I 'VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) [1B. VADOSE ZONE Zll CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ S. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING M. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRrMO/DAY) ESTIMATEDOWNTITY OF SUBSTANCE REMAINING 435 TANK FILLED'WTMINERT MATERIAL? <br /> psama ❑Yes ❑No <br /> Formerly SVVRCB Form B <br /> CUPAFORM(4/99) <br />