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w <br /> UNIFIED PROGRAM CONSOLIOATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> ! t-0 oages oer ranK) <br /> i <br /> 1 Page � of <br />' TYPE CF ACTION K]l I NEW SITE?ERMIT ❑ a AMENDEO PERMIT ❑ S. CHANGE OF INFORMATION) C i. -EMPORARY SITE CLOSURE <br /> (Checx one rte,only) rr, �" '] 7 P RMANEN,L`!CLOSED ON SITE <br /> 3. <br /> RENEWAL PERMIT ;Soeay reason-for rota)use only) (Saecry change-nor vocal use ontv) ❑ 3 -ANK REMOVED 130 O <br /> 3 ESUS NAME,Same as FACILITY NAME it CBA-Ooinq 3uWOSS ASI =AC:UTY'0# ' 1 I- <br /> ATION THIN SITE paonel) 13 <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK.MANUFACTURER COMPARTMENTALIZED TANK ❑ , <br /> / �e3 ;511. � <br /> 't--n-.�;ere one oage rot esm comoartmem. <br /> DATE iNSTA (YEAR/MO) ` TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 7LL^ 9D <br /> ADDITICNAf DESCRIPTION(For local use only) <br /> !I.TANK CONTENTS <br /> �y� TANK USE 432 'EfROLEUM TYPE <br /> xj <br /> MOTOR VEHICLE FUEL I,r 1a. REGULAR UNLEADED ❑ L LEADED Cl 5. :ET FUEL <br /> rlt ma ed.comorem Pewteum type) ❑1b. PREMIUM UNLEADED ❑ 1. 71ESEL ❑ 3. AVIATION FUEL <br /> Cl 2. VON-FUEL PETROLEUM <br /> ❑Ic. MIDGRADE UNLEADED ❑ 4 3ASCHOL j U 99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ COMMON NAME;/tent Hazamous.Matenats,n r9Ory pa{el i :AS#IhOm Haz.IX"Mve <br /> amnals InnrOry oage) <br /> 4 1A2AROOUS WASTE(IrrUudes <br /> Used Oil) I - <br /> i <br /> N WN <br /> --f III-TANK CONSTRUCTION <br /> TYPO OF TANK ❑ 1 SINGLE'NALL ❑ 3. SINGLE'MALL'MTH i. 31NGLE WALL MTH INTERNAL 3LAOOER SYSTEM <br /> ;Check one)tem ony) ? roUBLE:.VALL EX.cR10R M EM BRA N E'-N ER ❑15. .:NKNCWN <br /> ❑ 4. SINGLE'NALL.N A 4AUL7 <br /> L39. 7THER <br /> TANK MATERIAL-onmary(anK IJ . 3ARE S`EL U 3. =IBERGLASS;PL:STIC i. :ONCRE-E J 35. JNKNCWN <br /> (Checx one.tam ony) ❑ <br /> Z. STAINLESS STEEL Cl 4. STEEL:AD W/FIBERGLASS =RP SCMPATIBLE'Mi00%METHANOL 'J 39. OTHER <br /> REINFORCED Pr-AS7tC FRP1 <br /> ?ANK MATERIAL->econpary!anK ❑ ! 3.ARE 3 EEL ❑ 3. -1BE RGLASS 1 PLASTIC 3. =RP,OMPATIBL_N1100%METHANOL J 3i �JNKNC`NN <br /> (Checx one item only) Cl 2. STAINLESS STEEL Cl1. 37EEL AD W/F!9ERGL:SS ,,!,``3. =RP'ICN-CORROOIBLE:ACKET ]99. OTHER <br /> RENFORCED PLASTIC;FRP) <br /> ❑10. COATED STEEL <br /> !J 5. CONCRETE <br /> TANK',NTERIOR UNING r-I ❑ DATE:NSTA CD <br /> OR COATING '1 u RUBBER UNED U 3. EPDXY UNING 4�5�5. 3L:SS UNING 95. 'JNKNCWNA33 <br /> Cl Z. AL.KYO UNING U 4 -HENOUC UNING ! _�. JNUNED ❑39. OTHER 7 <br /> (Check one item ontv) FOrf al u e onl 1 <br /> OTHER CORROSION i ❑ MANUFACTURED CATHODIC �3. =ISERGLASS REINFORCED PI i GATE INSTALLED <br /> PROTECTION IF APPLICABLE PLASTIC J 35. UNKNOWN a3a _ <br /> AROTECTION ❑ 4 MPRESSED CURRENT '1 99. OTHER I 7 <br /> (Check one rtem ony) I [12- SACRIFICIAL ANODE 'Fpr) use ony) <br /> SPILL.AND OVERFILL (EAR INSTALLED TYPE(For tool use orky OVERFILL PROTECTION EQUIPMENT:vEAR INSTALLED <br /> ((check au tnal aopry) [_ L (: <br /> Cl +. SPILL CONTAINMENT I '❑ ! ;LARM3. ,LL-118E SHUT OFF VALVE <br /> ❑ 2. OROP TUBE C I ❑ ? 3ALL 7LOAT 4. '(EMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> �F SINGLE WALL TANK,Check al)that aooy): :F OOUBLE WALL TANK OR TANK WITH BLADDER!Check one dem onr4: <br /> ❑ VISUAL iEXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING IMTGI '] VISUAL(SINGLE'NALL,N VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ o. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> IJ 3. CONTINUOUSATG Cl i. GROUNDWATER 3. MANUAL.MONITORING <br /> a STATISTICAL INVENTORY RECONCiUAT1ON(SIR)t Cl d. TANK TESTING <br /> 31ENNIAL TANK TESTING [199. OTHER <br /> V TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) N =STiMATED CUANTITY OF SUBSTANCE REMAINING 435 -ANK FILJ_ED VMTH INERT MATERIAL? <br /> -adon$ '❑ <br /> CUPAFORM(4199) Formerly SWRCS Form 8 <br />