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U NIFI EDP ROGRAM CON SO LIDATED F O RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two Pages per tank) <br /> Page _ al <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 5. TEMPOPARY SITE CLOSURE O <br /> TYPE FACTION ❑ T. PERMANENTLYOLOSEDONSIT <br /> ❑3.RENEWAL PERMIT lSperiN meson-brbcal uae onryJ (Sposychaga-terimaluse Only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Be aaAC TY AMj0BA oing Business Ae) FACILItt IDN 1ITFMT <br /> LOCATIONW1THI SITE(Op Z usl) <br /> I.TANK DESCRIPTION <br /> TANK IDN TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea ❑ No <br /> If-yes',complete one page for earls compaNnent <br /> DATE INSTALLED(YE,"O) TANK CAPACi Y IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For bawl use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ S JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED 6. AVIATION FUEL <br /> (II/nadaecomplBM1la <br /> Pafmum Type) ❑lb. PREMIUMUNLEADEO ❑ 3. DIESEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑ta. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(hom Hazardous MasAab lnvanlorypage) CABp(/mm Hazartlous Materials lnventarypage) <br /> ❑ 4. HAZARDOUS WASTE(Irrcludes <br /> Used 010 <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. DOUBLE WALL 'p 4 SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary tank1 BARE STEEL ❑ 1. FIBERGLASSIPLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> Checkaneitemonly) ❑ 2. STAINLESS STEEL 04 STEEL CLAD PIARPBERGIS 08 . FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> RCED <br /> TANK MATERIAL-3awndary tank 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8 FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one ism onryJ ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD <br /> REINFORCED PLABERG TIC RPS❑ 9_ FRP NO&CORRODIBLE JACKET 099. OTHER <br /> ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> OATEINSTALLED <br /> TANK INTERIOR LINING 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNKNOWN431 <br /> OR COATING <br /> ❑ Z. ALKYD LINING ❑ d. PHENOLIC LINING ❑ B UNLINED 99. OTHER Forlocal use onlJ <br /> (Check om ism on ) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ d. IMPRESSED CURRENT 099. OTHER (Forlocal use only) <br /> Chack oma it..onM ❑ 2. SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwlocal use cnry) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check aft Pal appal 0 1, SPILL CONTAINMENT ❑ 1. ALARM - 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT__ 4. EXEMPT <br /> ❑ 3. STRIKERPLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check a8 Pe(eppl): IF DOUBLE WALL TANK OR TANK WITH BlAODER(Check one item only: <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ e. TANKTESTING <br /> BIENNIAL TANK TESTING ON, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATED U D(Y Y) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑Na <br /> Formerly SVJRCB Form B <br /> CUPAFORM(4/99) <br />