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ED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 ®Y/7/v <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION <br /> (Check one nem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY TAMC CLOSURE 430. <br /> ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify season) (Specifyreaon) 8.TANK REMOVED <br /> BUSINESS NAME(S.as FACILITY NAME or DBA-Doing moiness As) 3. FACILITY ID: a <br /> 1. <br /> - nzven � Tj <br /> LOCATION WITHIN SITE(Optienaq <br /> i 3qa K[ . Ma� S - 431. <br /> cc. �l � bL� ; _: <br /> I.TANK DESCRIPTION ' <br /> (A scaled plot planwith the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434, <br /> 1T�1 5 3 tL K-Yes•• <br /> complete one page for each anrymsment. <br /> DATE STALLED 435 TANK C A: I4IN GALLONS 436. NUMBER OF COMPARTMENTS <br /> (YEAR/MO) <br /> 43]. <br /> ADDITIONAL DESCRBTION(For local use only) <br /> 438. <br /> IL TANK CONTENTS <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 440. <br /> ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (Ifelecked,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED <br /> ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL 1199.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(fmm Hazardous Materials Inventory page) 442. <br /> ❑ 4. HAZARDOUS WASTE <br /> (Induds Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL El3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> (Check one item only) MEMBRANE LINER [195. UNKNOWN <br /> ❑2. DOUBLE WALL ❑q, SINGLE WALL IN A VAULT 1199. OTHER <br /> TANK MATERIAL-primary tends ❑I, BAREol ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. <br /> (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC FRP W/100%METHANOL <br /> TANK MATERIAL-secondary tank ❑1. HARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. FRP COMPTI MILE W/IWI.METHANOL ❑-95 445. <br /> (Check one item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL <br /> TANK INTERIOR LINING ❑1.RUBBER LINED <br /> [15. CONCRETE <br /> OR COATING ❑3.EPDXY LINING [015.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. <br /> ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLBJED ❑99.OTHER <br /> Check one item on] <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBEi <br /> ORCED PLASTIC ❑9UNKNOWN a8DATEINSTALLED 449. <br /> PROTECTION PROTECTION ❑4.IMPRNT ❑99.OTHER <br /> f A livable ❑2SPILL AND OVERFILL YEARINSTALLED 4545I. OVERFILI.PROTECTION EQUIPMENT: YEAR INSTALLED 452. <br /> (Check all that apply) F-11.SPILL CONTAINMENT ❑1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE <br /> [12.DROP TUBE ❑2.BALL FLOAT <br /> ❑3.STRIKER PLATE ❑4.EXEMPT <br /> IV.TANK LEAK DETECTION <br /> (A description bfthe monitoring program shall be submitted to the local agency.) <br /> IF SINGLE WALL TANK 453- IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. <br /> (Check all that apply) (Check one item only) <br /> 1:11. VISUAL(EXPOSED PORTION ONLY) 115.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING <br /> [14. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE , <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 156- TANK FILLED WITH INERT MATERIAL, 457 <br /> gallons ❑Yes ❑ No <br /> lu-' r -10003 <br /> UPCF hwfwre-6(1/99)-1/4 http://www.unidoes.org Rev.02/16/00 <br />