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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page,of TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF 11"TORMATION ❑ 6 To&-ORARY TANK CLOSURE 430. (Check one imm only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (sPe65,«) (Spccify rcmon) ❑ 8.TANK REMOVED BUSINESS NAME(Same.FACILITY DUMB ca DBA-Dcing B-ainm Ar) 3. FACILITY E,7 I nm"F�5Safewa Inc. _ - LOCATION WITHIN SITE(optional) 431. NE comer of West 11th Street and Corral Hollow Road �.,,. v<rm.�.y,''-z. •-� K _ t'�.,,y.,� .- TANK ID# 43i TANK MANUFACTURER a33 CON.PARTNTI NTALIZED TANK U Yes No 434. I -�:) Modern Welding Co.Inc. if"Y,;ccmpleta ere page fa each cc=pmtment DATE INSTALL ED 435. TANK CAPACITY N GALLONS 436 NUMBER OF CO,LIPARTMENTS 437. (YEAR(MO) 2002 March -29:690 \01000 2 ADDITIONAL DESCRIPTION cForlo`-cal uac auv) �i 438 ... '...,..� 4 r-r 2 TANK USE 439 PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2 LEADED ❑5. JET FUEL (ifchedced,wmplcu FvudeumType) [J 1b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2- NON-FUEL PETROLEUM ❑!c. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER. ❑ 3. CHEMICAL PRODUCT COMMON NAME(frm Ha=&d Statenah Inrmtory peat) 441. CAS#(from H=ui+ j Natant Inventory pege) 442. ❑ 4. HAZARDOUS WASTE REGULAR UNLEADED 8006-61-9 (Lu!uda U,e3 QD ❑ 95UNKNOWN �}(� - 443. '`Y TYPE OF TANK Lj 1. SINGLE WALL U 3. SLYGLE WALL WITH EXTERIOR Lj 5. SINGLE WALL WITH INTEILNAL BLADDER SYSTEM (Check one item only) MEMBRANE I= C195. UNKNOWN 2. DOUBLIi WALL 4. SINGLE WALL IN A VAULT 99. OT1R TANK MATERIAL-primary U-k 1. BARE STEL ❑3. FIBERGLASS i PLASTIC ❑5. CONCRETE 95.UNKNOW V 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGIASS ❑8. FRP COMPATIBLE ❑99.OTHER REINTORCEDPLASTICW(IW1,MEF-IANOL TANK MATERIAL-secondary tank 1, BARE STEEL 3. FIBERGLASSlPLASTIC ❑S. FRP COMPTIBLE W/IDO%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL LADCED PLASTIC(FRP) ❑9.PCOAON-SORRRP ODA13 JACKET ❑99.OTHER REINFTEDSTTEL 5. CONCRETE TANK INTERIOR LINfNG Ll L RUBBER LINED Lj 3.EPDXY LINII4fj 5.GLASS LINING [195.TJ`(KNOVY IN 446. DATE INSTALLED 447. OR COATING [12.ALKYD Li LING ❑4.PH:-:NOLIC LINING ®6.UNTL ItinD ❑99.OTHER Check one item onl OTHER CORROSION 1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALI ID 449. PROTECTION PROTECTION ❑4.r DRESSED CURRENT ❑99.OTHER (IfAtolicable) 1.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQLIPMENI: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONIAIN`fENT _2001_ Phil-Tite85000 ®1.ALAR\1 ❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2001_ OPW 61 T-7368 ❑2.BALL FLOAT ❑4.E�[FJviPT 3 STRIKER PLATE Tank Mfe Modvn Welldinx _._ {} �Y,c+- '�- �- _.hr. kt' s •.t � a.s.2.f' - '4ii -k-` ... 1 .� 2 � � tw ..i A �� -�''w'1'fi' 2e Puatt# lF �alsf �hitlel>�th�CicO q - IF SINGLE WALL TANK 457- IF DOUBLE WALL TANK OR TANK WM-I BLADDER 454 ^ (Check all that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE N 2.COT47INUOT S INTERSTITIAL,MONTTORLNG ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONTIORNCr ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TEST NG (SIR)+Bffi1DIIAL TANK TESTING �a ❑99. OTHER a} ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMANNG 456. TANK PALLED WITH INERT MATERIAL? 4 57 gallons ❑Yes ❑ No UPCF hwfwre-b(1199)-114 http://rvvTr'.uoldoea.org Rev.02116100 6 -d 0OZE 13r N3SU1 cIH Wd6t+ :� ZOOZ 60 NFJC