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UNIFIED PROGRAM CONSOLIDATED FORM I <br /> TANKS i <br /> Ui"MERG ROUND ST DRAG" TANKS -TANK PAGE 1 <br /> ' II <br /> OWOpag._+sperrank) I� <br /> t_ 'age - of <br /> i TYPE OF ACT'rN ❑1 NEW SITE PERMIT ❑ 4. AMENDED PERMIT ` C.+ANCE Oc INFCPMATION) ❑ 8. TEMPORARY SITE CII-OSURE <br /> (Check ane iter^:vy) '�J, ' <br /> ❑3.RENEWAL PERMIT A&W /0"'41 c ❑ 7. PERMANENTLY CLCSED ON SITE <br /> ISpec+fy reason.10,:ocal use only) (Speedy:harge-for local use only) ❑ g TANK REMC':ED 43 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA•Doing Busmess As) FACILITY 10 e 1 <br /> LOCATION �MIN SITE(Opllonai) 431 <br /> � `�'PTU S• r �' <br /> L TANK DEoCRIPTICN <br /> TANK€D# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes 2<11 <br /> Tq O (�f If'Yes',complete one page for each compartment <br /> DATE"NSTALLED(YEAR/M0) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ACCITIONAL DESCRIPTION(For)oeal uta only) <br /> TANK CONTENTS <br /> j� TANK USE 432 PETROLEUM TYPE <br /> D11 MOTOR VEHICLE FUEL ❑7a. REGULAR UNLEADED ❑ DED ❑ 5 JET FUEL <br /> (fFtn"ad,complete Pefroieum type) El lb PREMIUM UNLEADED 3 DIESEL ✓ ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MICGRADE UNLEACED ❑ 4 GASOHOL ❑99 OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4 HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Mat is Inventory page) CAS#(from Hazardous Ma-lanais inventory page) <br /> Use,,OA) <br /> N I <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3 SINGLE WALL WTH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check are item only) L!r z. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4 SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL3. FIBERGLASS!PLASTIC ❑ 5. CONCRETE ❑95 UNKNOWN <br /> (Check one item only) ❑ 2 STAINLESS STEEL ❑ 4 STEEL CLAD WlFIBERGLASS ❑ B FRP COMPATIBLE V.11100%METHANOL ❑99. OTHER <br /> lilEINFORCED PLASTIC[FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3, Fi9ERGLASS t PLASTIC ❑ 9. FRP COMPATIBLE Wi10C%METHANOL ❑95. UNKNOWN <br /> (Check one'em only) ❑ 2- STAINLESS STEEL ❑ 4 STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑59. OTHER <br /> REINFORCED PLASTIC{FRP) ❑10. COATED STEEL <br /> ❑ 5. CGNCRETE <br /> INTERIOR LINING El1. RUBBER LINED ❑ 3. EPDXY LINING ❑' 5, GLASS LINING ❑95 UNKNOWN433 DA7E INSTALLED <br /> OR COATING OR <br /> ❑ 2'.. ALKYD LINING El 4, PHENOLIC LINING ❑ B. UNLINED El 99 OTHER <br /> (Check one item only) )Far laaaf use only) <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3 F:BERGLASS REiNFCRCEC PLASTIC ❑95 UNKNOWN 434 <br /> DATE INSTALLED <br /> PROTECTION IDN IF IF APPLICABLE PROTECTION <br /> (Check one.tem ant ❑ 4. IMPRESSED CURRENT 1:199. OTHER <br /> (Ch <br /> Y) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check all that apply) <br /> 1 SPILL CONTAINMENT �--� t. ALARM 3. FILL TUBE SHUT OFF VALVE <br /> IROP TUBE 1d_"BALL <br /> BALL FLOAT El 4. EXEMPT <br /> - STRIKER PLATE <br /> IV, TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check ail that a;x6) _ 1 tF DOUBLE WALL TANK OR TANK WITH SLADCER rCheck one:tem criv. <br /> +. VISJAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1 iH[SUAL(SINGLE WALL IN VAULT CNLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG1 ❑ 8. VACGSE ZCNE 2. CONTINUOUS INTERSNTIAL MONITORING -. <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)> ❑ 9. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. GTNER <br /> V.TANK CLCS:JRE IMFORMATON 1 PERMANENT CLOSURE IN PLACE <br /> ES-IM4TED DATE LAST USED(YRIMO/DA!t ESTIMATED QUANTITY CF SUBSTANCE REMAWNG 435 1 TANK FILLED WITH INERT MATERIAL' <br /> later, <br /> ❑Yes ❑No <br /> 0* Kin I <br /> CUPAFOFrM(4139) Formerly SWRC8 Form 8 <br />