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Oct 23 OG 12: 11p owner 209-941 -0142 ��� P. S <br /> Il V-0I1n-1,4-b). <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE I <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION Cl L NEW PERMIT 0 4.AMENDED PERMIT 0 5.CHANGE OF INFORMATION 0 6.TEMPORARY TANK CLOSURE 419 <br /> (Geek as acmonl3D 3.RENEWAL PERMIT 0 7.PEI04ANENTLY CLOSED ON SITE <br /> (SPxFryrmwo) (Sp lfy nasm) ❑ 8.TANK REMOVED <br /> 13LIS[NESS NAME(S..FACILITY NMao,DSA-DovaBuslneu Asl 3. FACII.ITY ID: '� t. <br /> Wes!' ).4 ove el4¢ v on <br /> LOCATTON WITHIN SITE(opiorup yJ1 <br /> r17LfI w--51 zarnm 51d+r1(roe) <br /> I.TANK DESCRIPTION, <br /> Amaizd lot' buo.with the locatium ofthe UST Sysiem incl8 ' 'buHdvl andlandmarks shelIbe submitted to the beat agency.) - <br /> TAP7K ID W 432. TANK MANUFACTURER 435. COMPARTMENTALIZED TANK Yes No 414. <br /> -1^p 1['Yes,"<ompkleoxryge Wreuh rmparnrcnL <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS <br /> (YEAR/MO) 433. <br /> 12000 p <br /> ADDITIONAL DESCRIPTION porko!nsc pil5'> 43e <br /> 11.TANK CONTENTS <br /> TANK USE 431. - <br /> PETROLEUM TYPE yep <br /> OL 1. MOTOR VEHICLEFUEL 01.. REGULAR UNLEADED 02. LEADED 05.JET FUEL <br /> pfM keM1mmle'Peaok.TP) Pt lb. PREMIUM UNLEADED <br /> ❑3. DIESEL ❑b. AVIATION OAS <br /> 0 2. NON-FUEL PETROLEUM OIc. MIDGRADE UNLEADED 04. GASOHOL ❑99.OTHER: <br /> 0 3. CHEMICAL PRODUCT COMMON NAME(tom Ha .Fwriie lrnseco,, e) 441. CASP(aum Hae ,e Matmahlm<m.N p) 442 <br /> 0 4. HAZARDOUS WASTE <br /> O+a'lvea ux40iD <br /> 0 95.UNKNOWN <br /> -. III:TANK CONSTRUCTION - - - <br /> TYPEOFTANK 01. SINGLE WALL 3. SINGLE WALL WITH EXTERIOR 05, SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> (Check one in...Iy) MEMBRANELINER 095. UNKNOWN <br /> ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-pimayma 01. BARE STEEL IX 3. FIBERGLASS/PLASTIC 5. .CONCRETE 95.UNKNOWN 444. <br /> (Chzk om!am om39 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS 08. FRPCOMPATIBLE 099.OTHER: <br /> REINFORCED PLASTIC W%IOD%METHANOL <br /> TANK MATERIAL-secondary nvk 1.BARE STEEL mp 3,FIBERGLASS J PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 095.(MKNOWN 445, <br /> nccrkonc item only) 02. STAINLESS STEEL 04. STEEL CLAD W/FWERG1ASS 09. FRPNON-CORRODABLEJACKET 099.OTHER <br /> REINFORCED PLASTIC(FRP) 0 10. COATED STEEL <br /> 5. CONCRETE <br /> TANK INTERIOR LINING El 1.RUBBER LINED U 3.EPDXY LINING 0 S.GLASS LINING Cl 95.UNKNOWN uG DATE INSTALLED a43. <br /> OR COATING 0 2.ALKYD LINING [14.PHENOLIC LINING 0 6.UNLINED 0 99,OTHER <br /> CL<ck eve Itern.0A <br /> OTHER CORROSION I.MANUFACTURED CATHODIC 03.FIBERGLASS REINFOWED PLASTIC 95.UNIGNGWN 448 DATE INSTALLED ;49. <br /> PROTECTION PROTECTION ❑C IMPRESSED CURRENT 099.OTHER <br /> 7'A licablc 02.SACRIFICIAL.ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED 450 1 TYPE 451. OVERPILLPROTEC170NEQUIPMENT- YEARINSTALLED 452. <br /> (Check all thatapply) gl L SPILL CONTAINMENT MI.ALARM ®?.FILL TUBE SHUT OFF VALVE_ <br /> 2.DROP TUBE I'2,BALL FLOAT_0 4.EXEMPT3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A desc'ri lion ofthe molutoiingpmgiam'sball be mb3ltidad to Loc local 5 gene .)' <br /> IF SINGLE WALL TANK 453, IF DOUBLE WALL TANK OR TANK WTH BLADDER 454. <br /> (CMck all that apply) (Check one item only) <br /> ❑1. b':SUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) 01.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 02.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE Vk2.CONTINUOUS @ITERSTITIAL MONITORING <br /> [13.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING <br /> El4.STATISTICAL INVENTORY RECONCILIATION OB.TANK TESTING <br /> (SIR)i BIENNIAL TANK TESTING 0 99.OTHER <br /> V.TANK CLOSURE INFORMATION 1.PERMANENT CLOSURE IN PLACE <br /> F.97WAT7DOATELASTLISED(YRMI0@AYI 455ESTIMATED QUANTITY OF SUBSTANCE REMAIN[ G 456. TANK FIL45D N'ITH INERT MATERIAL? 4'7 <br /> Baum ❑ -a 0 No <br /> UFCF hwfwm b(1/99)-114 htlp:Uwww.unidocs.org Rev.02/16/00 <br />