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NIFIED PROGRAM CONSOLIDATED FO..... <br /> 7TANK]SUNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> Page <br /> TYPE OF ACTION 1.NEW SITE PERMIT ❑ 4- AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one N19m-W ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Spedlymeson-/orMdt use <br /> anM (sPeu+Y change'for local use arty) ❑ 6. TANK REMOVED 470 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID 0 1 <br /> 1 17 4 LC-,55 III MR-r&nruo <br /> LOCATION WATHIN SITE(OpbofW 431 <br /> 3.42 M W <br /> L TANK DESCRIPTION <br /> TANK 10• TANK MANUFACTURER - COMPARTMENTALIZED TANK pr Yes <br /> -� ❑ No <br /> NQLA5 4'-z •�r- H'Ya-.OMPIOW am page for each oornpw,,.s. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 2.�/ '%ova, �Pt-t l Z <br /> ADDITK7NAL DESCRIPTION(Forbcal use cry) <br /> If.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL Ole. REGULAR UNLEADED ❑ 2. LEADED ❑ 5- JET FUEL <br /> prmakked,complete PMmleum TOO) Wills. PREMIUM UNLEADED ❑ 3. DIESEL ❑6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> COMMON NAME(hone Hazardous MebrlYr Inurrory page) CAS N Arae Hazallous MalerfW Imntory p" <br /> ❑ 4. HAZARDOUS WASTE pndudes <br /> Used ON) <br /> 095 UWNOWN <br /> IN.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one Morn only) W2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> ❑ 4.SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-Primary tank al. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check we item only) ❑ 2. STAINLESS STEEL Lt.4. STEEL CLAD WFIBERGLASS ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-so.A ry tank ❑ 1 BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 6. FRP COMPATIBLE VW100%METHANOL ❑95. UNKNOWN <br /> (Check one 00M W90 ❑ 2. STAINLESS STEEL D 4.STEEL CLAD VWFIBERGLASS 0 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ <br /> S.CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING. ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4.PHENOLIC LINING Sr.. UNLINED ❑99. OTHER <br /> (Check one item OnW <br /> For local use onl <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3.FIBERGLASS REINFORCED PLASTIC 1395. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 1.IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (Fw/ocal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use omw OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check al that apply) <br /> I� 1. SPILL CONTAINMENT q <br /> 1� i ­ I.C�-I tp,1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 10 2. DROP TUBE 0 A'2. BALL FLOAT ❑ 4. EXEMPT <br /> I�3. STRIKER PLATE <br /> IF SINGLE WALL TANKK(Check aN that a IF DOUBLE WALL TANK OR TANK WITH BLADDER one Nem on : <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE W:2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG - ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)i ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SMCB Form B <br />