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*[FIED PROGRAM CONSOLIDATED FOf!!7I TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages per tank) Page 1 of 2 TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 19 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same.FACILITY NAh1Bor DBA-Dom,Bosinaa N) 3. FACILITY ID: L ARCO Facility No. 9600 LOCATION WITHIN SITE(optioneq 431. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submittedto the local agency.) TANK ID# 432- TANK MANUFACTURER 433, COMPARTMENTALIZED TANK ❑Yes M No 434. 1 Modern Welding If"Yes,"complete one page for each compartment. DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 04/15/95 15031 0 ADDITIONAL DESCRIPTION(Far loml use only) 435. II.TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ®la. REGULARUNLEADED ❑2. LEADED [15. JET FUEL (Ifchecked,complete Petmlwm Type) [I lb. PREMIUM UNLEADED El 3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haaardous Materiah inventory page) 441, CAS#(9om He w...Materials lmeatc,page) 442. ❑ 4. HAZARDOUS WASTE Gasoline 8006-61-9 Oncludes Used Cil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [:15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primus tank ❑1. BARE STEEL L]3. FIBERGLASS/PLASTIC L1 5. CONCRETE [3 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC L]8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ®4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 443, OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED [199.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN "a. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER Applicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 1995 [11.ALARM unk ®3.FILL TUBE SHUT OFF VALVE _ ®2.DROP TUBE 1995 ®2.BALL FLOAT wk. ❑4.EXEMPT ®3.STRIKER PLATE 1995 IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457. A I �^1..!�//�6t/ gallons' A e Q' ///��',�y�,,r� �� , ❑Yes ❑ No UPCF hwfwre-b(1/99)-2/4 http://www.unidoes.org { rl_�"�QQy�� Rev.02/16/00 (/I1CN