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Adik <br /> U N IF I EDP ROG RAM CONSOLIDATED FORMjtank) <br /> J TA <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (tura pages <br /> Page _ O/ _ <br /> ❑ 5.CHANGE OF INFORMATION) ❑ 9. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT [3 <.AMENDED PERMIT 07. PERMANENTLY CLOSED ON SITE <br /> (Check one item only) <br /> 03.RENEWAL PERMIT (SPeg(ry,raaaan.Mhaalum wNyl (Specify change-brbceluse Onry) ❑ B. TANK REMOVED OO <br /> BUSINESSN ME(Same as FACI Eor DBA or Bwinees As) <br /> FACILITY IDA 1'iFi Tp 1 <br /> LOCATION'MTHIN SITE(Opa'oINO 431 <br /> L TANK DESCRIPTION <br /> TANK IDtl , JTANK MANUFACTURER' COMPARTMENTALIZED TANK IP ❑ Yes <br /> w#9`+ 1/ ^ D Yaamrompleone page lOr exhw arMent. <br /> TANK CAPACITY IN GALLONS NUMBER OF COMPAA TM <br /> RENTS <br /> DATE INSTALLED(YEARIMO) /® DO� <br /> /0 3 <br /> ADDITIONALD CRIPTIONIForlocalaseonty) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ S. JET FUEL <br /> ��! ❑ta. REGULAR UNLEADED ❑ Z.LEADED <br /> (d <br /> MOTORVEHICLEFor warnFUEe� ❑ 3.DIESEL ❑ S. AVIATION FUEL <br /> p/meM1eq mmpbro Pefrobum Type) �b. PREMIUM UNLEADED N. OTHER <br /> D 2. NON-FUELPETROLEUM E]j, MIMPADE UNLEADED ❑ 4.GASOHOL <br /> D 3.CHEMICAL PRODUCT COMMON CASA(Irom Hazallow Malonate lnwnbrypape) <br /> NAME(hom Nazallous Mafanals Inwnbrypage) <br /> D 4, HAZARDOUS WASTE(lnclwlea <br /> Used OR) <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 01. SINGLE WALL 0 3.SINGLE WALL WITH 0 S. SINGLE WALL VATH INTERNAL BLADDER SYSTEM <br /> Ate/ EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Check mn dem MW 2, DOUBLEWALL D 4, SINGLE WALL IN A VAULT N. OTHER <br /> TANKMATEnmary bankD 1 BARESTEEL LA <br /> ❑ 3. FIBERGUSS/PSTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Check era ifinhrom anMay) ❑ 2. STAINLESS STEELSal( STEELCUDWIFIBERGUSS ❑ 9. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-mmrMery lank D.1 BARE STEEL 0 3. FIBERGLASS I PLASTIC 0 e. FRP COMPATIBLE W1100%METHANOL 95.N. OT HUNKNER_(Check one item only) 0 U <br /> 2. STAINLESS STEEL 0 4.STEEL CUD W/FIBERGSS 0 9, FRP NON-CORRODIBLE JACKET <br /> REINFORCED PLASTIC(FRP) [110, COATED STEEL <br /> 0 5. CONCRETE DATE INSTALLED <br /> TANK INTERIOR LINING 0 J, RUBBER LINED 0 3. EPDXY LINING A❑�5. CUSS LINING 095. OTHERUNKNO.M433 <br /> ORCOATING D 4. PHENOLIC UNING EO e. UNLINED ❑99. OTHER FOTEINSTALLE <br /> ❑ 2.ALKYD LINING ,` PATE INSTALLED <br /> (Check one item on <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGUSS REINFORCED PLASTIC 95. UNKNOWN 434 <br /> PROTECTION IF APPUCABLE PROTECTION 0 4. IMPRESSEDCURRENT 099' OTHER (Falowlum Onlyl <br /> (Chock ane item Dory) 0 2. SACRIFICIALANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Felocal am MI <br /> (Check all that appryl D 1. SPILL CONTAINMENT ❑ 1.ALARM __ 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROPTUBE 0 2, BALL FLOAT_ 0 4. EXEMPT <br /> D 3. STRIKER PLATE _� <br /> N.TANK LEAK DEFECTION -- <br /> ' IF DOUBLE WALL TANK OR TANK WITH BUDDER Check one item only: <br /> IF SINGLE WALL TANK CM1eck all that applY) ❑ 1, VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) <br /> ❑ <br /> B. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING. <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 T GROUNDWATER 0 3. MANUALMONITORING <br /> D 3, CONTINUOUSATG <br /> 0 4, STATISTICAL INVENTORY RECONCILIATION(SIR) 08. TANK TESTING <br /> BIENNIAL TANK TESTING - 0W. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE I PLACEANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LArjTU ED(YRRAOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> galbna ❑Yee 0 No <br /> 1 <br /> 0/3 <br /> 149 <br /> , Formerly SVVRCB Form B <br /> CUPAFORM(4199) • • <br />