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1IFIED PROGRAM CONSOLIDATED FC TANKS mak- s" 3' M UNDERGROUND STORAGE TANKS - TANK PAGE 1 �� o page at�fl ( (TA per ank) \T> Page_of TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) �3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 34 FACILITY ID: 1. MAIN STREET KCO kMP(v\- Kis EWTei ts6 L r- Ar 0 O Io11-1.1�- m6 /+ LOCATION WITHIN SITE(Optional) 431 Iloo S.MAIN STR.ECT NIX WTECA C-P, 9533,1 ��yy ty r i. a :3x.U.J-• ^�4 a I.7C7.� V �sE -; '`''•P+rl 'S Mimi,t9 `S•.R' "t".•.. •:.- )^ sem.` ,� M.t a C � „ . ( _Scaled plot plan y�tt�'t� c rib'.T T.s ftetn.titc ud rlgl ulldings End Ian Ma l e $b t�t thti,idCa1-40n_ays r TANK[/]7](y� p� q� 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 434. 4 r r P,!/�(/ J�F_K/(E•� If"Yes,"romplete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. IQ9j I o� I n,Doo '_' ADDITIONAL DESCRIPTION(For local use only) 438 eie eyi Uzt A rE`' ME airs j� E`cY'fMT. V sr - _ , T„>» t s J•t" Il l,al1lJ - . @'a'trW'• ? %r�u,• �m,-'�..s:iS,at ...r__.. :�t".:dpi.r:9i. ..'.Fa;S��`r�'.�+.n•:�+�..iaa. TANK USE 439. PETROLEUM TYPE 140, XI. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (I(checked,complete Petroleum Type) )(Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE - ":''-flncluda Used Oil) ❑ 95.UNKNOWN. ,� , ,��,. ��s z,4.r'a '�'�,a I� AL1�'C:�NSTIY�[J�I471�T'' ��-6ru�.�f-��:`' +.�. �;� ,� ' ,, • ' •y �i '14, TYPE OF TANK - ❑I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER El95. UNKNOWN 2. DOUBLE WALL Q4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank EjI. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE El99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC [18. FRPCOMPTIBLE W/IDO%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑3.EPDXY LINING E3 S GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING X6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION 4.IMPRESSED CURRENT ❑99.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EOrJIPMENT: YEAR INSTALLED 452. (Check ail that apply) 1.SPILL CONTAINMENT ivy_ 1.ALARM 1004 •p 9,FILL TUBE SHUT OFF VALVE .DROP TUBE 24fp 4 2.BALL FLOATI�"Q4.EXEMPT 13:.STRIKER PLATE Ill zk-4 % iyF' 1� �T;TANKI t1I£;DETi1ffG 'IO s - S '_i" - !I� r�r� �d'S^ ('+,•;y.s ;,;, :� -�ira r= At scri't, n SEt}Se mbnlfo'nn =ro rir.sialf bt'stibmrtfed[o thb loc`�1'a e c ^� p ati r " °fi ru Jl"Y 4. .... R gA _ IF SINGLE WALL TANK 453• IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑ I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE '<2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING 99. OTHER 1 � V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE `'`-'` STIMATED DATE LAST USED(YR/MO/DAY) 455' ESTBv1ATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.03/16/00