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0%NIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />(INo pages pertank) <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT <br />(CMck one item orly) <br />❑ 3. RENEWAL PERMIT (SPsaTyrsason ro xaaw. voA <br />❑ 5. CHANGE OF INFORMATION) <br />(Spsary dugs - /or local . OW <br />❑ S. TEMPORARY SITE CLOSURE <br />❑ T. PERMANENTLY CLOSED ON SITE. <br />❑ S. TANK REMOVED 430 hI <br />BUSINESS NAME (Sm'n as FAG�UTY NAME w DIM,DI Bwi.. A3) <br />FACILITY ID N <br />DIBA- <br />101�4pjj <br />11 <br />LOGTION WITHIN SITE (Op6orea7 431 <br />�rF4 3& c <br />1. TANK DESCRIPTION <br />TANK ID N <br />TANK MANUFACTURER <br />COMPARTMENTALIZED TANK Na <br />rIIPIaI Nmmp❑ ent <br />�✓ <br />DATE INSTALLED(YEARRAO) <br />TANK CAPACITY INGALLONS <br />NUMBER OF COMPARTMENTS <br />' <br />ADDITIONAL DESCRIPTION (ForWal ase Orly) <br />IL TANK CONTENTS <br />TANK USE 432 <br />PETROLEUM TYPE <br />MOTOR VEHICLE FUEL <br />❑ 1a. REGULAR UNLEADED <br />❑ 2. LEADED <br />❑ 5. JET FUEL <br />(tt mukeE, compMM1 PSI -Tyya) <br />PREMIUM UNLEADED <br />❑ 3. DIESEL <br />❑ 6. AVIATIONFUEL <br />❑ 2. NON-FUECHEMICAL PETROLEUM <br />❑ lc MIDGRADE UNLEADED <br />❑ 4. GASOHOL <br />❑ N. OTHER <br />CT <br />❑ 3. CHEMICALPRODUCT <br />COMMON NAME PAT Hazalloux Marorids InrenroNpaYaJ <br />CAB N (hom Hezallous McNMIa Invsnforypops) <br />❑ 4. HAZARDOUS WASTE (1wJuaea <br />WAS <br />"'a" 0" <br />' "ON <br />0 UNKNOWN <br />III. TANK CONSTRUCTION <br />TYPE OF TANK ❑ 1. SINGLEWALL ❑ S SINGLEWALLWITH ❑ 5. SINGLE WALL NTH INTERNAL BI -ADDER SYSTEM <br />(Crack orro sem oNy) DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br />�❑ 4. SINGLE WALL IN A VAULT <br />0 9. OTHER <br />TANK MATERIAL - primary tank ❑ 1 BARE STEEL ❑ 3. RBERGLASSIPIASTIC ❑ 5. CONCRETE ❑W. UNKNOWN <br />(Ceadwnaamamy) ❑ 2. STAINLESS STEEL STEELCLADWIFIBERGLASS ❑ 8. FRP COMPATIBLE WI100%METHANOL 099. OTHER <br />s. <br />REINFORCED PLASTIC (FRP) <br />TANK MATERIAL - ismMary laM ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL El 95 UNKNOWN <br />(OMck. abm Orly) ❑ 2_ STAINLESS STEEL X4. STEEL CLAD W/PIBERGLASS ❑ 9. FRP NON -CORRODIBLE JACKET ON. OTHER <br />REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL <br />❑ 5. CONCRETE <br />TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNKNOWN433 DATE INSTALLED <br />OR COATING <br />❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING �- UNLINED 099. OTHER <br />Forlocal wa <br />OTHER ON <br />❑ 1 MANUFACTURED CATHODIC <br />❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br />DATE INSTALLED <br />PROTECTIONIF <br />PROTECTION IF APPLICABLE <br />PROTECTION <br />❑ 4. IMPRESSED CURRENT 089. OTHER <br />I <br />(CMck aMihm oMW <br />❑ 2 SADRIFIQML ANODE I <br />(Fwbcalun Orly) <br />SPILL AND OVERFILL <br />YEAR INSTALLED <br />TYPE(F.,b .as wry) <br />OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED <br />(C%xck aaaMf apply) <br />❑ 1. SPILL CONTAINMENT <br />❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br />❑ 2. DROPTUBE <br />❑ 2. BALL FLOAT ❑ 4. EXEMPT <br />❑ 3. STRIKER PLATE <br />. N. TANK LEAK DETECTION <br />IF SINGLEWALL TANK CM aflrMla ): I IF DOUBLE WALL TANK OR TANKWITH BLADDER CMck wa Kem onlyj <br />❑ 1, VISUAL(EKPOSEO PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL (SINGLE WALLIN VAULT ONLY) <br />❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING <br />❑ 3. CONDNUOUSATG ❑ T. GROUNDWATER ❑ 3 MANUAL MONITORING <br />❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ 8. TANKTESTING <br />BIENNIALTANK TESTING 0 , OTHER <br />V. TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br />ESTMATED DATE T ED(YPoMODAY) <br />ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 <br />TANK FILLED WTH INERT MATERIAL? <br />oslb s <br />1 ❑ Yss ❑ NO <br />CUPAFORM (4/99) `� J <br />Formerly SWRC�jfarm B <br />