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4 '3 12 _F �► <br /> =UNDERGROUND <br /> FIEDPROGRAMCONSOLIDlily TK] <br /> STORAGE TAN <br /> ►U('(,(JL''Vf^' "� r ta <br /> Page _ of <br /> `may /� TECLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFI Y ,lH' CLOSED ON SITE <br /> (Check one from pnyp <br /> ❑3.RENEWAL PERMIT (Specltyreaaon-torkkeluae amy) (Spsay chargsbr ) 430 <br /> t <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Buslneea Asl FACILITY ID 0 - <br /> Spft,) j6 tQvlf) <br /> LOCATION WITHIN SITE(Op' a9 431 <br /> 5 c Ate <br /> I.TANK DESCRIPTION <br /> TANK IOM TANK MANUFACTURER COMPARTMENTALIZED TANK [I Y., Na <br /> IPYal wmplete one papa far eerh wmi lment. <br /> DATE INSTALLED(YEAWMO) <br /> TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> U S� <br /> ADDITIONAL DESCRIPTION(For boar use Only) <br /> It TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE 135. JET FUEL <br /> ❑ 1.MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 11 2. LEADED <br /> (It"AaC,<.,l Petmle✓m Type) ❑tp. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADEUNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCTDA$P(hum HazeNam Mabdals Inventory page) <br /> COMMON NAME(from Hazaltloua Maferiala Inuenbry page) <br /> ❑ 4. HAZARDOUS WASTE(Intlutles <br /> Used Dip <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> heck one dem only) ❑ 2. DOUBLEWALL ❑ 4.SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> K MATERIAL-Primary Onk1BAR ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> ❑ . <br /> (Check one dem anty) ❑ 2 STAINLESS <br /> STEEL ❑4 STEEL Ctl PILASTIC(FRPS EI 8L FRP COMPATIBLE W11017%METHANOL N. OTHER <br /> - <br /> REINFORCED <br /> TANK MATERIAL.sacweary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 0. FRP COMPATIBLE WI1o0%METHANOL ❑95. UNKNOWN <br /> (Check pre Item Only) ❑ 2. STAI NLESS STEEL ❑ 4. STEEL CLAD <br /> REINFORCED FIBTICGFRP) [19, FRP NON-CORRODIBLE JACKET ❑99.OTHER <br /> Elio COATED STEEL <br /> ❑ 5. CONCRETE <br /> DATE INSTALLED <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING D 9. UNKNOM433 <br /> OR COATING ❑ 4. PHENOLIC LINING [:30. UNLINED ❑99. OTHER <br /> ❑ 2. ALKYD LINING Forlocal use on ) <br /> ne <br /> Check oitem on DATE INSTALLEO <br /> OTHER CORROSION [31. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPUCABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (Forlocal use only) <br /> (Check one,Ram only) ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forloolfusapal <br /> (Chapk all that apply) ❑ 1. SPILL CONTAINMENT ❑ 1.ALARM _ ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT__ ❑ 4. EXEMPT <br /> ❑ 3. STRIKERII <br /> IV. TANKILEAKOETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER(Cl one item onl <br /> IF SINGLE WALL TANK(Check elf Thal III <br /> ❑ 5. MANUAL TANK GAUGING(MT ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 1, VISUAL EXPOSED PORTION ONLY) <br /> El 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 5. VADOSE ZONE <br /> ❑ 3. CONTINUOUSATG El ?. GROUNDWATER C3 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ e. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAS,rrUSED(Y OIDAY) q( / <br /> V�L <br /> gallons ❑Vas al <br /> Formerly SVI Fom B <br /> CUPAFORM(4/99) <br />