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awt� u■ w unr� ws� FLED PROGRAM CONSOLIDATED FORM TANK PR# UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC# (two pages per tank) Page 2 of 3 TYP:�F CTION t NEWSITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE Cheem only) rj•:_rs yti't'y5ryI^.a".. ❑ 3 RENEWAL PERMIT aer^?'3""<.+^"r;,, }"�w's'�"k'x'"'4'3'•'�x'r-•—r (Spatfyaaon-for local tvcovo ( %` ❑ 7 PERMANENTLY CLOSED ON SITE hb ; )(Spenryreason Cor localtneaily) wx,ds Cep' : d+�. ttF "se.+'��.,�„.t , ❑8 TANK REMOVED a3o — BUSINESS NAME(Same as FACILITY NAME or DBA Domg Btu,ncsa As) FACILITY ID PR# l 3 LOCATION WITFAN SITE(Opwsal) 431: ' PHONE I TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency) TANK IDIS 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 V h 1-',l 0 w I If Yes complete one page for each compartment DATE INSTALLED(YEAR/MO) 435 TANK CAPACI rY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ym JJ n 2 r1{�h o c9 r✓- ADDITIONAL DESCRIPTION(For local use only) 439 II TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ I MOTOR VEHICLE FUEL ❑ 1 a REGULAR UNLEADED ❑ 2 LEADED ❑ 5 JET FUEL ' (lfmarkedcomplctcPctraleumType) lb PREMIUMUNLEADED ❑ ❑ 3 DIESEL ❑ 6 AVIATION FUEL ❑ 2 NON FUEL PETROLEUM ❑ lc MIDGRADE UNLEADED ❑ 4 GASOHOL 99 OTHER ❑ 3 CHEMICAL PRODUCT COMMON NAMEfrom Hazardous Matmats inventory' ry pogo) 4 HAZARDOUS WASTE 44t CAS#(from Hazardous Ms[crtals Inventory page) ❑ 442 (Includes Used Oil) �39$ UNKNOWN ' III TANK CONSTRUCTION TYPEOFTANK l SINGLE WALL ❑ 3 SINGLE WALL WITH [] 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95 UNKNOWN ❑ 2 DOUBLE WALL ❑ 4 SINGLE WALL IN VAULT ❑ 99 OTHER K MATERIAL primary tank I BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5 CONCRETE ❑ 95 UNKNOWN 444 (Chock one nem only) ❑ 2 STAINLESS STEEL ❑ STEEL CLAD WIFIBERGLASS ❑ 8 FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99 OT HCR ' TANK MATERIAL secondary tank ❑ 1 BARE STEEL ❑ 3 FIBERGLAss i mASTIC ❑ 5 CONCRETE ❑ 95 UNKNOWN 445 (Chock one stem only) ❑ 2 STAINLESS STEEL ❑ 4 STEEL CLAD WIFIBERGLASS ❑ 8 FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) © W COATED STEEL ❑ 99 OTHER ' ❑ 5 CONCRETE TANK INTERIOR LINING 1 RUBBER LINED ❑ 4.17 OR COATING ❑ ❑ 3 EPDXY LINING ❑ 5 GI ASS LINING 95 UNKNOWN 446 DATI INSTALLED (Check one nem only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING R"! UNLINED ❑ 99 OTHER _ (For local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC REINFORCED PLASTIC 9S UNKNOWN 448 449 PROTECTION IF APPLICABLE PROTECTION E] }FIBERGLASS REDATE INSTALLED (Check one Item only) ❑ 2 SACRIFICIAL ANODE ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (For local use only) ' SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 (Check all that apply) ❑ 1 SPILL CONTAINMENT E]E] 2 DROP TUBE I ALARM E] 3 FILL TllBE SHUT OFF VAU ❑ 3 STRIKER PLATE E] 2 BALL E] 4 EXEMPT FLOAT ' IV TANK I EAK DETECTION(A desorption of the monitoring program shall be suhmsaed to the local agency) IF SINGLE WALL TANK(Check all that apply) 453 1F DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ' ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SING1 E WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑ 3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE IMATED DATE LAST USED(YRlMO/DAY) ass ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIALS 457 ❑ Yes ❑ No UPCF(12/99 revised) 1