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I -bi 3I)qxg.�__t.2_ o - <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />?rra <br />PIA» L a <br />1YP!OI AC2U1 <br />131. NEw 9Rt PERS, ❑ A. AMRNDTiD PERMIT 5, CHANGE OF INFORMATION) ❑ 6. li1R'ORARr 9171 QOiL11O <br />ICIM1rA eAwrIIY) O T. PERMANEHILYCLOSED ON SITE <br />03. RENEWAL ( naaon-ArbcM is oyl'1 ! rnenpe- marW) ❑ 6. TUM REMOJED 4b <br />PERMIT <br />BVS,NF$$ wWE 15ru u FALKITY NAYE w DBA - Duq BluelePE A•1 3 <br />FACETTY IDE <br />1 <br />�. <br />1 FA35L+ i <br />LGCATIOI MET)M SITE (OPO..qV I <br />1. TANK DESCRIPTION <br />ANK1 E 3 43 <br />TANK MANUFA U 433 <br />COMPARTMENTALIZED TANK ❑ YSA Aw 4N <br />TAc <br />Il -Yep .-,lAIe. Ppe (Pa ePdl l <br />r'c_�, <br />DATE 1 )) a}S <br />TANK iTY IN a <br />NUMBER OF COMPARTMENTSU <br />Q <br />e � V <br />ADgTICNAI CESCRIPTION IFw bol uv weY) 4J6 <br />II. TANK CONTENTS <br />TNM USE 439 <br />PETROLEUM TYPE a46 <br />1 MOTOR VEHICLE FUEL <br />❑ 19. REGULAR UNLEADED Cl 2. LEADED Cl 5, JET FUEL <br />( rnrMe. awICRM1 PNMeum Type) <br />Clip. PREMIUMUNLEADED gr� <br />p4A- DIESEL 116. AVIATION FUEL <br />Cl 2. NONFUELPETROLEUM <br />Cl lc MIDGRADE UNLEADED ❑ A. GASOHOL Cl 99. OTHER <br />❑ 3 CHFMl AL PRODVCT <br />COMMON NAME f6enl Hl'". Melnom,. In., PApl) wl <br />CASt(hem lM2e/eWe NAM1AMe lnarnlwY ppe) -2 <br />O A HAZARDOUS WASTE(In . <br />Use GO <br />❑ 95 UNKNOMA <br />I <br />It. TANK CONSTRUCTION <br />TYPE OF 1. ❑ 1 SINGLE WALL ❑ 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM W <br />(Cbee wnrem wary) �2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br />O A SINGLE WALLINAVAULT Cl99OTHER <br />TANKMATERAL-pnmrYuwl Cl 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ a. CONCRETE C3 95 UNKNOWN au <br />(Cue wle rem"yo Cl 2. STAINLESS STEEL ;K4. STEEL CLAD ❑ 6. FRP COMPATIBLE WlIW%METWWOL 0e9. OTHER <br />WIFIBERGLASS <br />REINFORCED PLASTIC FRP <br />TANK MATERIAL-aevLr19rYArt0 1 BARE STEEL Cl J. FIBERGLASS/PLASTIC ❑ 6. FRP COMPATIBLE WIIW%METHANOL C1 9S UNKNOWN 'A9 <br />(Ch4 ane le -n only, Cl 2 STAINLESS STEEL .v4 STEE_^_LAD WIEIBERGIASS ❑ 9. FRP NON-CORROOIBLE JACKET 0 OTHER <br />REIWOtCED PLASTIC (FRP) Cl 10. COATED STEEL <br />❑ 5. CONCRETE <br />TANKMTERIOR LINING Cl 1 RUBBER LINED Cl 3. EPCXYLINING Cl 5. GIASS LINING 095. UNKNOWN 446 DATE INSTALLED Ml <br />OR COATING <br />❑ 2. A11(YO LINING ❑ 4. PHEaKJLIO LINING .�6. UNLINED ❑99. OTHER <br />C6 y wry rMn Fwlaol usP only, <br />OTHERCORROSION ❑ I MANUFACTUREDCATHOOIC Cl 3. FISEPOLASS REINFORCED PLASTIC IK95 UNKNOWN M6 DATEINSTALLEO w9 <br />PROTECTION IF APPLICABLE PROTECTION <br />❑ A. IMPRESSED CURRENT 0 . OTHER <br />fC64o orr rem awYl Q I. SACRIFICIAL ANODE lFwbol uae 9nyl <br />SPILL AND C.TRFILL YEAR INSTALLED 450 -PE fFw fool use only) 451 <br />OVERFILL PROTECTION EOUIPMENT YEAR INSTALLED 4u <br />❑ Cl /'�1 <br />([pock yAPPY,ler Aly) ❑ 1 SPILL CONTAINMENT <br />1. ALARM 3 FILL TUBE SHUT OFF VALVE J_ <br />pp,D�{.� <br />❑ 2. OROPTVBE _S7] <br />Cl 2. BALL FLOAT q1kV ❑ 4 EXEMPT <br />' ❑ J STRIKER PLAPf <br />` N. TANK LEAK DETECTION <br />IF ANGLE WALL TANK (Check am mel AMY). 453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER (CneFk orn dem only, 4 <br />Q 1 . -_-- EXPOSED PORTION GNLYI C35 MANUAL 74'., GAUGING IMTG) <br />❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) <br />O 2 A_7CWTIC TANK GAUGING(ATGI Cl 6 VADOSE ZC-8 <br />Cl 2. CONTINUOUS INTERSTITIAL MONITORING <br />❑ J CC%7♦ UIXJUS ATG ❑ T GROUNOWA`c9 <br />❑ J MANUAL MONITORING <br />❑ 4 5'A-STICAL INVENTORY RECCNCIUATION (SIR1 • ❑ 6. TANK TEST'r; <br />B'P,\X TANK TESTING C] 99 OTHER <br />V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br />ESTIMATE --ATE LAST USED IYR/IACVOAYI 455 ESTIMATED OUANTIT'-- SUBSTANCE REMAINING 1% TANK FILLED WITH INERT MATERIAL? 4571 <br />galbnF Cl Yea ❑ No <br />UPCF I!C- <br />Formerly SWRCR Form N <br />