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Owner Nam.i(from Section 1) Location(from Section II) Page No.45–of 6 Pages <br /> x Identification No.(e.g.,ABC-123),or I Tank No. I Tank No. Tank No. I Tank No. I Tank No. <br /> Arbitrarily Assigned Sequential Number(e.g.,1.2.3...) <br /> 1.Status of Tank <br /> (Mark all that apply X) Currently in Use Q Q Q QQ Q <br /> Temporarily Out of Use <br /> Permanently Out of Use [ Q LQ Q Q <br /> Brought into Use after 5/8/86 QQ Q Q Q CQ <br /> 2.Estimated Age(Yeats) >^, <br /> 3.Estimated Total Capacity(Gallons) ( r\LO I <br /> 4.Material Construction Steel <br /> (Marc onea M) Q Q Q Q <br /> Concrete <br /> Fiberglass Reinforced Plastic Q QQ QQ Q Q <br /> Unknown <br /> Other,Please Specify <br /> S.tntemai Protection <br /> (Mark ail that apply X) <br /> Cathodic Protection <br /> Q Q Q Q <br /> Interior Lining(e.g.,epoxy resins) <br /> None [Q Q Q Q Q <br /> Unknown Q Q Q Q Q <br /> Other.Please Specify <br /> 6.External Protection QQ Q Q Q CQ <br /> Cathodic Protection <br /> (Mark all that apply X) <br /> Painted(e.g..asphaltic) Q QQ Q Q Q <br /> Fiberglass Reinforced Plastic Coated Q Q Q [Q <br /> None Q Q Q [Q Q <br /> Unknown <br /> Other,Please Specify <br /> 7.Piping <br /> Bare Steel <br /> (Maris all that apply) <br /> Galvanized Steel <br /> Fiberglass Reinforced Plastic <br /> Cathodically Protected QQ Q [Q Q Q <br /> Unknown CQ Q Q Q Q <br /> Other.Please Specify <br /> t <br /> 8.Substance Currently or Last Stored a. Empty Q Q] Q Q Q <br /> in Greatest Quantity by Volume <br /> b. Petroleum <br /> (Mark a1/that apply X) Diesel -- <br /> Kerosene <br /> Gasoline(including alcohol blends) [Q] Q Q Q <br /> Used Oil <br /> Other.Please Specify <br /> c. Hazardous Substance <br /> Please Indicate Name of Principal CERCt.A Substance <br /> OR <br /> Chemical Abstract Service(CAS) No. <br /> Mark box f&if tank stores a mixture of substances <br /> d. Unknown <br /> S.Additional Information(for tanks permanently <br /> taken out of service) <br /> a. Estimated date last used (molyr) I LILT a -�11 — <br /> b. E_timated quantity of substance remaining (gal.) �' ! <br /> c. '.lark box 2 If tank was filled with inert material <br /> (e.g..sanc.concrete) <br /> n IG i <br />