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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Mo pages per tank) �!1 i III�II ?age � of I TYPE OF ACTION . NEW SITE PERMIT ❑ s. AMENDED PERMIT Q S. CHANGE OF INFORMATION) ❑ 5. -E.MPORARY SITE CLOSURE ;Check one item only/ , ❑ i xRMANENTLY CLOSED ON SITE F C 3.RENEWAL PERMIT Soersly lesson-for local use only) i SpeaN change•.'ovocar use only) ❑ 3. 'ANK REMOVED 430 r11' U$P §�O E(Same as F/CILITY VAME or 013A-Doingdusmass AS)C S� �� _ ION WTHIN SITE phonal) 43 I.TANK OESCRIPTION TANK MANUFACTU TANK i0 a RER / /� COMPARTMENTALIZED TANK Yes C1 "I J5 U / /�(_/ .h-Yes'.'Ari,w.le ane POW for oanWatarient DATE INSTALL (YEAR/MO) TANK CAZC YIN GALLON NUMBER OF COMPARTMENTS oe ADDIrIONAL DESCRIPTION(Forlocal use only) (005Y (Q 0.TANK CONTENTS / TANK USE 412 oETROLEUM TYPE JLC '. MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑ Z. LEADED ❑ 5. JET FUEL (Il rked.complete Petroleum Type) ❑1h PREMIUM UNLEADED ❑ 3. DIESEL ❑ d AVIATION FUEL ❑ Z. NON-FUEL PETROLEUM i I❑Ic MIOGRAOE UNLEADED ❑ S. GASOHOL I ❑99. ;;TI•IER 3. CHEMICAL PRODUCT ❑ + HAZARDOUS WASTE(InUudes COMMON NAME(from Marardous Materials unerkory,page) I =AS a(hdn rivankw Malarlsls/rlvereory page) Uses DipL_35UNKNOWN II I ^I III.TANK CONSTRUCTION TYPE OF TANK ❑ t, SINGLE'NALL ❑ 3. SINGL='NALL'MTH ❑ S. SINGL:-'NALL'MTH INTERNAL 3LAODER SYSTEM (Cheek one item only) 2- DOUBLE'NALL EXTERIOR MEMBRANE LINER ❑95. •JNKNOVM ❑ A. SINGLE WALL!N A VAULT ❑39DTHER TANK MATERIAL-onmary,tank ❑ !. 3ARE STEEL X. -19ERGLA$S!PLASTIC i. :ONG4E i c .J 95. UNKNOWN (Cheek one item only) ❑ Z. STAINI III STEEL ❑ 4. TEL CLAD W/FIBERGLASS ❑ 3. ?RP r.-OMPATIBL E'M100%METHANOL ❑99. OTHER REINFORCED PLASTIC:FRP) TANK MA TERIAI seeotwary tank TJ 1. 3ARE STEEL ❑ 3. .FIBERGLASS!PLASTIC 3. =RP,OMPATIBL_'M100%METHANOL L-195- UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD VWFIBERGLASS L.i 9. =RP NON-CORROD18LE JACKET ❑99. OTHER QEINFORCED PLASTIC iFRP) ❑•0. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING ❑ t RUBBER LINED ❑ 3. -EPDXY UNING S. GLASS UNING ❑45. UNKNOWN413 GTE INSTALLED OR COATING (Check one item ononly) ❑ Z. ALKYD LINING ❑ d. PHENOUC LINING C25. UNLINED ❑99. OTHER ,Fwlocal use an W .1 OTHER CORROSIONDATE INSTALLED PROTECTION IF APPUGBLc C1 1. MANUFACTURED CATHODIC C3 3. :1BERGLASS REINFORCED PLASTIC 45. UNKNOWN 43a PROTECTION Q i. IMPRESSED CURRENT ❑99. OTHER Check one item only) ❑ 2, SACRIFICIAL ANODE For local use aM) SPILL AND OVERFILL YEAR INSTALLED TYPE IFa W*use only) I OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Cheek all that apply) I [] 1. SPILLCONTAINMENT 'I ❑ 1. ALARM ❑ 1 --ILL'UBE SHUT OFF VALVE ❑ 2- DROP TUBE i ❑ 2. 3ALLFLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check as tnat aopyl: I IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onI ❑ !, 'VISUAL(EXPOSED PORTON ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) 101. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ d. VADOSE ZONE -CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER 3. MANUALSIONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)* ❑ d. TANK TESTING 31ENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE -ESTIMATED DATE LAST USED(YR/MO/DAY) yt ` I cSTLMATF�QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? ! I ]allons j ❑veS No OS/-5 (�) r, 17 CUPAFORM(4/99) Formerly SWRCS Forth 8