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UNIFIED PROGRAM C ONSOLIDATED FORM <br /> =(� <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> Page _ of _ <br /> TYPE OF ACTION 01.NEW SITE PERMIT D 4. AMENDED PERMIT X15. CHANGE OF INFORMATION) D e. TEMPORARY SITE CLOSURE <br /> (Check one item anty) ❑ ]. PERMANENTLY CLOSED ON SITE <br /> D 3.RENEWAL PERMIT (Spedynason-/prlouluse omy) (Specity cherps-brbcel use only) ❑ 8. TANK REMOVED 430 <br /> FACILITY IDN 1l 1 <br /> BUSINESS NAME(Seme as FACILITY NAME or DBA.Doing Business As) Q (/ <br /> as f &ca .� <br /> LOCATION WTHIN SITE(Oplional) r, 431 <br /> I.TANK DESCRIPTION <br /> TANK IDN Q ' TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes o <br /> If Wea',pomplele one page Iw ask,n wmparlment. <br /> DATE INSTALLED(YEAMMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ww� '5001 <br /> ADDITIONAL DESCRIPTION(Forlwal use anty) <br /> Il.TANK CONTENTS <br /> TANK USE 432Elb. PREMIUM <br /> TROLEUM TYPE ❑ 5. JET FUEL <br /> X1. MOTOR VEHICLE FUEL R UNLEADED . LEADED <br /> (Ilmarhesr,complete Pefrini Type) UNLEADED 0 3. DIESEL ❑ e. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM DEUNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> D 3. CHEMICAL PRODUCT @arrl Hazallous Mabdars Inwntarypge) CAS N(/mm Hazardous Materials Inwnbrypege) <br /> 0 4. HAZARDOUS WASTE Oppludes <br /> Ned Oil) <br /> n 95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL 0 3. SINGLEWALLWTH 0 5. SINGLE WALL VWTH INTERNAL BUDDER SYSTEM <br /> EXTERIOR MEMBRANE LINER D95. UNKNOWN <br /> (Check one item only) 02 DOUBLE WALL D q SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL.primary tank X1 BARE STEEL 0 3. FIBERGLASS/PLASTIC D 5. CONCRETE 095. UNKNOWN <br /> (Check wro demway) 0 2. STAINLESS STEEL D 4 LCILAD PILABERGIPS 0 e. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REE <br /> TANK MAT ERIAL-sewndary tank 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ e. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one it..any) ❑ 2. STAINLESS STEEL D 4 STEEL CI.AD REINFORCED PLABTIC(FRPS D 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> Elio. COATED STEEL <br /> ❑ 5. CONCRETE <br /> OATEINSTALLED <br /> TANK INTERIOR LINING D 1. RUBBER UNED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑f95. UNKNOWN433 <br /> ORCOATING g, UNLINED /CJ B9. OTHER <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING (Forlocal use on 1 <br /> (Check am ttem aril) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 <br /> PROTECTION IF APPUCABLE PROTECTION <br /> ❑ I. IMPRESSED CURRENT 9. OTHE0. (Farlocal use only) <br /> (Check one ibm only) ❑ 2. SACRIFICIAL ANODE <br /> SPI LL AND OVERFILL YEAR INSTALLED TYPE(Farlawl use any) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ad that appy) 0 1 SPILL CONTAINMENT ❑ 1.ALARM _ 0 3, FILL TUBE SHUT OFF VALVE <br /> II �'h/1F ❑ 2. DROPTUBE 0 2, BALL FLOAT D 4. EXEMPT <br /> 0 3. STRIKER PLATE <br /> P4. TANK LEAK DETEC710N. <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item On'): <br /> IF SINGLE WALL TANK(CM1eck ell that appl <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) 5. MANUALTANK GAUGING(MTC) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUS ATG ❑ ?. GROUNDWATER 0 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)? ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAGT USED M0/DAY) ESTI MATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons 0 Yes No <br /> �� D 0la57D <br /> T� v51sS3 � <br /> CUPAFORM(4/99) . • �I� I Formerly$WRCB Form B <br />