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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKSI <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />PK rrBo <br />_ 5 ( Papa 3 a <br />TYPE OF ACTION ❑ i. NEWS PERMIT ❑ 1. AMENDED PERMrt � 3. C1MNC2E OF INFORIM110NB ❑ T PERMANENTLY ROLE CLOSOSE0 RE <br />(CNq os /w Aa+W <br />ON <br />13 3. RENEWAL ( ...-brl9ol.7w ) f Mary- rr/a aVYl ❑ I. TANK REMOVED 430 <br />PERMIT <br />BUSINESS NAME (Same v FACILITY NAME a DBA- DR Bua/Naa A•1 l <br />FACILITY ID / <br />- <br />1 <br />3IPT \A 14 <br />I <br />- <br />IOCJLT10N YYD.NI SffE (Dp/orMO <br />Ul <br />1. TANK DESCRIPTION <br />TANKIDN32 <br />ANN MANUf U <br />- ^ <br />t <br />COMPMTMENTAIIZEp TANK ❑ Yaa No <br />11-Yai. mmpaa wta PWaMaaN rn. <br />ay <br />'V` <br />An <br />DATE INS 1 F •y- <br />ANK ITY IN <br />•b <br />NUMdtM OF COMPARTMENTSU <br />8- <br />ACIXTIONK CESCRIPTIp4 (FLA bol uv RrYY1 I <br />•3/ <br />II. TANK CONTENTS <br />TANK USE 439 <br />PETROLEUM TYPE <br />••p <br />K T MOTOR VEHICLE FUEL <br />❑ la REGULAR UNLEADED 2 LEADED <br />❑ 5 JET FUEL <br />IN m.r taroNN PHft. TY'Pa <br />A❑ <br />Cl A(rF) ,9. PREMIUM UNLEADED y J. DIESEL <br />Cl 9. AVIATION FUEL <br />❑ 2. NOM-FUELPETROLEUM <br />❑ 1c MIDGRADE UNLEADED Cl 4. GASOHOL <br />Cl 99. OTHER <br />❑ 3 CHEMICAL PROg1CT <br />COMMON NAME/Ymm Naa.N-M-- <br />vl <br />CA$/fM1wn WaaNnuf MalanMa fiNrMwY gpal <br />u} <br />01.H DOUS WASTE(lnauda <br />U GO <br />0 g UNKNOWN <br />BI. TANK CONSTRUCTION <br />TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH <br />❑ 5. SINGLE WALL HATH INTERNAL BLADDER SYSTEM <br />••3 <br />(Lhedwraemaral'! 2. DOUBLE WALL EXTERIOR MEMBRANE LINER <br />❑95. UNKNOWN <br />❑ 4. SINGLE WALL IN A VAULT <br />on, OTHER <br />TANK MATERIAL -onm"SYN ❑ 1 BARE STEEL 3. FlBEAGIASSIPLASTIC <br />❑ 5. CONCRETE ❑ 95. UNKNOWN <br />•M <br />,❑1 <br />(Ch.e or tam PWp ❑ 2. STAINLESS STEEL Ip A. STEELCLAD <br />❑ B FRP COMPATIBLE W/100%METHANOL [IN OTHER <br />NIFIBERGLASS <br />REINFORCED PLASTIC FRP <br />TANK WTERIAL aaTUMary nrB ❑ 1 RMI STEEL 3. FIBERGLASS I PLASTIC <br />08 FRP COMPATIBLE WIIM%METWWOL 0 9. UNKNOWN <br />••5 <br />�❑N <br />ICnaw ane.em onryl ❑ 2 STAINLESS STEEL Iy 4 STEE_ CLAD WIMSERGLASS <br />❑ 9 FRP NONCORROOIBLE JACKET ❑99 OTHER <br />REINFORCED PLASTIC (FRP) <br />Cl 10 COATED STEEL <br />Cl 5. CCNCRETE <br />TANI( INT RQi LINING ❑ 1 RUBBER LINED Cl 3. EPCSY LINING <br />❑ 5. GLASS LINING ❑ 95 UNKNOWN vB DATE INSTALLED <br />a•1 <br />OR COATING <br />❑ 2. ALKYD LINING Cl 1. PHENOLIC LINING <br />X5. UNLINED IJ 99 OTHER <br />Cllay wla aAvll ryK <br />Fw bOluvM I <br />OTHER CORROSION Cl 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN v! DATE INSTALLED <br />u9 <br />PROTECTION IF APPLICABLE PROTECTION ❑ 1. IMPRF_SSEDCURRENi <br />❑ 99. OTHER <br />!CA•v F­aem PKY1 ❑ 2 SACRIFICIAL MODE <br />(FLA boluM <br />SPILL AND O.'ERFILL 'EAR INSTALLED 450 ' RE /Fort I wa 0WY) <br />451 <br />OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED <br />452 <br />8-� 96� <br />❑ L ALARM ❑ FILL <br />fCMckMmar +RPIYI Cl 1 SPILLCONTAINMENT <br />3 TUBE SHUT OF VALVET00' <br />(J'2 . DROP TUBE R -Sb <br />❑ 2. BALL FLOAT 8�&b ❑ • EXEMPT <br />f Cl 3 ST RAPER PLAJ( u -� <br />` N. TANK LEAK DETECTION <br />IF SWGLE WALL TANK (CAeaa ae Ihal aoPYA <br />453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check em nem 9WY1 <br />ASI <br />❑ 1. ':'S--. EXPOSED PORTION ONLYI Cl 5 MANUAL Tom'., GAUGING IMTG) <br />Cl I VISUAL (SINGLE WALL IN VS',LT ONLY) <br />❑ 2 .,7CMATICTANKGAUGINIG(ATG4 Cl e VADOSE Z^_'.E <br />❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br />Cl 3 =N-NUOUS ATG Cl T GROUNOW--ER <br />❑ 3 MANUAL MONITORING <br />❑ a 5'<-ISTICAL INVENTORY RECCNCIUATION (SIR' • ❑ 8 TANK TEST",G <br />S'E%%X TANK TESTING ❑ 99 OTHER <br />I <br />V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PUCE <br />ESTIMATE -ATE LAST USED IYRIMO/CAYI ASS ESTIMATED OUANTITV_F SUBSTANCE REMAINING Im TANK FILLED WITH INERT MATERIAL' <br />457I <br />gallant <br />Cl Yn ❑ No <br />UPCF C 5 - <br />`/ Ifto <br />Formerly SWRCS Form R <br />