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IFIED PROGRAM CONSOLIOATEO FD TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (twv pages per tank)- Page at TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE (Check one item onw ❑ T. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spealyr.eson-Icrlawluse.w (Specilycharge-rorlawllrsa Doty) B. TANK REMOVED 430 BUSINESS NAME(Sam.as FACILITY NAME or OBA-Dom g Busmass As) FACILITY ID Is t Leos a � Z LOCATION WITHIN SITE(Oy0one9 431 1.TANK DESCRIPTION TANK 101s TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No 51st- I uN .K."6 Q It'Yes.wmpbte one page for etgnwmpanment. DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 1C1CAIS IOOo ADDITIONAL DESCRIPTION(Forlacal use onty) IL TANK CONTENTS TANK USE 0.12 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑1.. REGULAR UNLEADED ❑ L LEADED ❑ S. JETFUEL (IlmeMd.complete Petroleum Type) 11 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑to MIOGRAOEUNLEADEO ❑ 4. GASOHOL 099. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4, HAZARDOUS WASTE(hwYWes COMMON NAME(emn HazaNpus Malemis lnwMarypage) CAB 9(hpm Hazames Materkls lnyenmrypage) Users 0" 95 UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL'MTH ❑ S. SINGLE WALL WITH INTERNAL BUDDER SYSTEM (Checko ed.only) ❑ 2. OOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑Be OTHER TANK MATERIAL-primary tank I. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEELCLADW/FIBERGLASS ❑ e. FRP COMPATIBLE V0100%METHANOL 099. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tan. ` 1 SARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 9. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (CMck.naibm.my) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/F18ERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 09B OTHER REINFORCED PLASTIC FRP) 010 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY UNING ❑ S. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER Dheck ore item on ) Fcrhowl useo OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑B9. OTHER (Dheck are ibm only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEARINSTALLED TYPE(Far kxal use only) OVERFILL PROTECTONI EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1. SPILLCONTAINMENT _ ❑ t. ALARM ❑ 3. FILL TIKE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check ak that a Wy- IF DOUBLE WALL TANK OR TANK WITH BLADDER ICheck ane item only).' ❑ 1. VISUAL(EXPOSEDPORTION ONLY) ❑ 5. MANUAL TANK GAUGING IMTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 9. VADOSEZONE ❑ Z CONTINUOUSINTERSTTTTALMONITORING 133. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ B. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE UST USED(YRIMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑NP CUPAFORM(4/99) . • Formerly SWRCS Form 8