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+ D PROGRAM CONSOLIDATED FOa ;fill <br /> 3! �T <br /> TANKS (aUNDERGROUND STORAGE TANKS -TANK pN (TWo pages per tank) <br /> Page_of <br /> 4 AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 410. <br /> TYPE OF ACTION �NEW PERMIT ❑ ❑ 7.pERMANENTLY CLOSED ON SITE <br /> Ich�"rc irem"wy) ❑ 3.RENEWAL PERMIT �- ❑ S.TANK REMOVED <br /> (Specify ra°^) (Specify raso^) 1. <br /> BUSINESS NA�E(Sa"cm FACIUTY NAME or DBA-Dein,B"smess Aa) ]. FACILITY ID: <br /> E 16 li o�: 57e- ( 16../ 411. <br /> LOCATION W IN SITE(096"w) <br /> TANK DESCRIPTION <br /> \ X• (A enc <br /> sealed, lot Ian with the location of the UST system <br /> including buildmgs and13andrnarlapsubmmittedto the ag YesNo 434. <br /> ANK ID# 432. TANKMANUFACVRERNUem.TANKCAPACITYMGALLONS 'J6 NUbS q1T. <br /> ATE INSTALLED ass. <br /> a ®D 41,. <br /> ADDITIONAL DESCRIPTION(For lone use only) <br /> II.TANK CONTENTS <br /> a10. <br /> TANK USE 419' PETROLEUM TYPE <br /> ❑ 1. MOTOR VE3tICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. LET FUEL <br /> (irchecked•c"nyleee L.EType) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. .i�'-LOTION GAS <br /> 99.OTHER: u2. <br /> ❑ 4. GASOHOL <br /> 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNi-FADED ❑ ul <br /> CAS#(6om HazaeEom Mazerub Invent"?page) <br /> ❑ 3. CHEMICAL PRODUCT COMMONNAME (fm"+lfae"rdo"a Meteiahl"vexorypaae) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Imleda Ua Oil <br /> 49s.UNKNOWN . <br /> III.TANK CONSTRUCTION «3 <br /> TYPE OF TANK SINGLE WALL 7. IEEMMBRANE LINER EXTERIOR O 9i SLNGT N Wl3'AI.1LL WITH INTERNAL BLADDER SYSTEM <br /> (Check one imm only 4. SINGLE WALL IN A VAULT ❑99. OTHER w. <br /> ❑2. DOUBLE WALL ❑ 95.UNKNOWN <br /> TANKMATERIAL-pt^'m9�k BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE <br /> IChea om;e^1O11y) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRPar 1MPA�BL OL ❑99.OTHER: <br /> REINFORCED PLASTIC <br /> I. BARE STEEL 3. FIBERGLASS/PLASTIC e. FRP COM <br /> p'I'®LE W/IDDY.MEfHANOL 95.UNKNOWN eas. <br /> TANK MATERIAL-secondary tank _ <br /> (Check one imm only) ❑2. STAINLESS STEEL❑4' REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEODABLE]ACKET ❑99.OTHER <br /> 5. CONCRETE WN w. DATEINSTALLED u7. <br /> TANK INT'cRIOR LLNT�G 1.RUBBER LINED 3.EPDXY LINING 5.GLASS IINLNG ❑99.OTTER <br /> OR COATING C12.ALKYD LINING ❑4.PHENOLIC LINING [�f.UNLQ'fED <br /> Check one imm only) u,. 'DATE INSTALLED u9. <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC ❑4.V.�PREG.SSEDCFD PLASTIC ❑99.OTTER WN <br /> PROTECTION PROTECTION <br /> f A Liable) ❑2.SACRIFICIAL ANODE 451. OV'ERFB1 PROTECTLON EQNPMEM: YEAR INSTALLED a32 <br /> SPILL AND OVERFILL YEAR IN.S`T�A ED ase. TYPE ❑1 ALARM ❑3.FILL.T()BE SHITC OFF VALVE -_ <br /> (Check all That aPp1Y) 0 1.SPILL CONTACONTAINMENTMC ❑2-BALL FLOAT- [14.EXEMPT <br /> 2.DROP OBE <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring Pmgmm shall be submitted to the local agency.) DER 4� <br /> as3. IF DOUBLE WALL TANK OR TANK WITH BLAD <br /> IF SINGLE WALL TANK (Check tme imm only) <br /> (Check all shat apply) 5.MANUAL TANK GAUGING [3 1.VISUAla(SINGLE WALL IN VAULT ONLY) <br /> 13EtP <br /> 1. VISUAL( OSED PORTION ONLY) 13CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) [3 6.VADOSE ZONE [3 2. <br /> ❑7.CONTINUOUS ATG <br /> [17.GROUNDWATER ❑3.MANUAL MONITORING <br /> [34. STATISTICAL D,VENTORY RECONCILIATION ❑S.TANK TESTING <br /> (SIR)�BIENNIAL TANK TESTING ❑99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE--PLACE 4s7 <br /> a55. 4�' TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED OTE LAST L'SED(YRMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REVI.ALNLNG ❑Yes ❑ No <br /> ` .g gallons <br /> so <br /> /118 Rev.02/16100 <br /> UPCF hwfwrc-b(1/99)-1/4 http:/lwvvw.unidocs.org <br />