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UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Iwo pages pertanYJ <br /> �J <br /> Pa9r <br /> 5.CHANGE OF INFORMATION) ❑ A TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT [1 a. AMENDED PERMIT [3 T. PERMANENTLY CLOSED ON SITE <br /> (Cn«YoM imY,ontA <br /> 0 RENEWAL PERMITS bN«al uxr anly) ❑ 9 TANK REMOVED q0 <br /> A3y9YBUSINESS NAME(Sams»FACILITY NAME«O I^9Q FA 100° _ a•• <br /> JJ�i/4tAr/7 <br /> LOCATION WITHIN SITE(OpY=^+B 401 <br /> L TANK DESCRIPTION <br /> NK O�7 bSQ NK MANUFACTURER COMPARTMENTALIZED TANK ❑ Y» *nL <br /> AIDa 5 /I /, (/a II Yai.mmplala ana pa9a la aatltwmpa <br /> L. IvL9 NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEA 0) <br /> TANK CAPACITY IN GALLONS <br /> /i!z _r av <br /> ADDITIONAL DESCRIPTION(P9IYKal uta OW <br /> IL TANK CONTENTS <br /> TANK USE 422 PETROLEUM TYPE ❑ 5. JET FUEL <br /> REGU LEAD ❑ 2.LEADED <br /> (QJ 1. MOTOR VEHICLE FUEL 5. IES EL [16. ANFUEL <br /> RlmaArd,FompNb P.1.4,THIN) ID. PREMIUM UNLEADED _ ❑99. OTHER <br /> ❑ 2. NON.FUEL PETROLEUM tc MIDGRADE UNLEADED <br /> ❑ 5. CHEMICALPRODUCT COMMON CASa(hom MuaKom Mandalf lnlanbrypa9al <br /> NAME(avm Hau�doua MaNna0lnMnfory pa9r) <br /> 94. HAUROOIJSWASTE fI«IUEr+ <br /> U+rd QB <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK <br /> ❑ J. SINGLE WALL 5. SINGLE WALLV+ITM ❑ 5. SINGLE WAIL VATH INTERIULBLADOER SYSTEM <br /> ...---/// <br /> EXTERIOR MEMBRANE LINER 0g5. VNNNOWN -: <br /> (Car*arN dam onM Id 2. DOUBLE WALL 'Q 4 SINGLEWALLIHAVAULT 099. OTHE0. <br /> / ❑95. UNKNOVM <br /> ONCRETE <br /> TANK MATERIAL-PrimaryUk Cl 1, BARE STEEL D. FIBERGCA DWFISR GU55 [3 BFRP COMPATIBLE W/1C0:Y METHANOL ❑99. OTHER <br /> ❑ S. C <br /> r,.k ona Rem omy) ❑ 2. STAINLESS STEEL [34 STEELUWIFIBE . <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•+ ^o+tl Mnk Cl 1. BARE STEEL 1uFes'2 FIBERGLASS I PLASTIC ❑ a FRP COMPATIBLE WI100%CKETMETHANOL ❑95. UNKNOWN <br /> rm <br /> (CYack arra drm amyl ❑ 2. STAINLESS STEEL ❑ A STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORR0019LE JA <br /> CNET ❑99. OTHER <br /> R EINFORCED PLASTIC(FRP) [110 COATED STEEL <br /> O 5. CONCRETE DATEINSTALLED <br /> ❑ 1. LINED 5.GLASS LINING 095. UNKNOWN. <br /> RUBBER L <br /> TANK INTERIOR LINING ❑ J. EPDXY LINING <br /> OR COATING ❑ 4. PHENOLICLINING ❑ 8. UNLINED ❑99.OTHER orb9al uta oM) <br /> ❑ 2. ALKYD LINING OATEINSTALLEO <br /> k onr iNm on I <br /> OTHER CORROSION 5. UNKNOWN 4Ba <br /> PROTECTION IF APPLICABLE L PROTECTION CATHODIC ❑ D. FIBERGSEDCU REINFORCED FUSTIC 099. OTHER <br /> ' PROTECTION � �. IMPRESSED CURRENT (Forbcaluv oNy) <br /> rC kpna iNm any) Cl 2. SAGRMOMLANODE OVERFILL PROTECTION EOVIPMENT:Y RINSTALLED <br /> SPILLANOOVERFILL YEARINSTALLED TYPE(Fabcal ufs only) <br /> (CaKYNfIUNPPIV) - ❑ 1. ALARM EW S FILL TUBE SHUT OFF VALVE$ <br /> $PILL CONTAINME <br /> ❑ 2. BALL FLOAT- 0 4, EXEMPT <br /> 5. STRIKER PLATE <br /> - . N.TANK LEAK DETECTION ...:.:• <br /> IF DOUBLE WALL TANK OR TANK WITH BUDDER fCnac4 onr ifam aMd: <br /> WSINGLE WALLTANK as Nafap F ❑ 1. VISUAL(SINGLEWALLIN VAULT ONLY) <br /> ❑ S. MANUAL TANK GAUGING(MTG) J <br /> ❑ 1. AUTOMIE%POS KGAUGtOG(ATG) sill CONTINUOVSINTERSTITULMOHITORING <br /> ❑ i CONTINUOUS <br /> GAUGING(ATG) ❑ a. VAOOSEZONE <br /> �;I CONTINUOUS ATG <br /> ❑ T. G0.0UNONATER ❑ 2. MANUAL MONrtORING <br /> ❑ 4. STATISTICAL INV9QORY RECONCILIATION(SIR) Cl 9. TANKTESTING <br /> BIENNIALTAN.TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION f PERMANENT CLOSURE IN PLACE <br /> 405 TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YRRAOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> - -�9albna <br /> [3 Y., ❑No <br /> FOfrne(ly SVVRC9 Form <br /> CUPAFORM(4199) <br />