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dry F 1 <br /> R UNIFIED PROGRAM CONSOLIDATED FOR <br /> V 1 1� TANKS <br /> UNDERGROUND STORAGE TANKS-TANK Curt <br /> (two pages per tank) <br /> Pape _ of <br /> TYPE OF ACTON ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSURE ` V <br /> (Check one item only} ❑ 7. PERMANENTLY CLOSED ON SITE 1 <br /> ❑3.RENEWAL PERMIT (specify Mason-foe loco/useonly) (SpecifycMYnge-Por local useenW B. TANK REMOVED 430 <br /> 13USINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDM H" 1 <br /> LOCATION WITHIN SITE(Optrona9 431 l] C-1 ! <br /> I.TANK DESCRIPTION <br /> TANKD t S - TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ yes ❑ No <br /> l\J Ii'Vea',complete one page for each comportment. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(ForleuI use oM9 <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1.MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (/f marked.complete Petroleum Type) ❑ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1t L41DGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3.CHEMICAL PRODUCT CAS 0(from Nazerdous Materials Inventory page) <br /> COMMON NAME((rom Hazardous Malerials lmrnfory pope) <br /> ❑ 4. HAZARDOUS WASTE(lndudes <br /> Used C* <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check one ifem an)y) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑.9.OTHER <br /> TANK MATERIAL-primary tank ❑ I: BARE STEEL ❑ 3. FIBERGLASS J PLASTIC ❑ 5.CONCRETE ❑95. UNKNOWN <br /> {Chock one Rem onry) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE W1100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS f PLASTIC ❑ e. FRP COMPATIBLE WII00%METHANOL 095. UNKNOWN <br /> (Check ane R.m oNy) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99.OTHER <br /> - REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS LINING ❑95. U14KNOYM433 OATS INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ e. UNLINED ©99. OTHER drkxal use <br /> (CAock one item <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3. FlBBRGLA55 REINFORCED PLASTIC ❑95, UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099.OTHER (Forloul uss only) <br /> (Cheek one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(Forlocal use onto OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chock W that apply) ❑ i SPILL CONTAENMENT ❑ 1.ALARM ❑ 3.FILL TUBE SHUT OFF VALVE <br /> ❑ 2 DROPTUBE _ ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> - ❑ 3. STRIKER PLATE <br /> ... .... <br /> _ <br /> W. TANK LEAK 13PTECTIRN <br /> IF SINGLE WALL TANK Check eN fhatap IF DOUBLE WALL TANK OR TANK WITH BLADDER ons tram <br /> MM❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTlNUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑4, STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING ©99, OTHER <br /> V.TANK CLOSURE INFORMATION t PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOIDAYI I.i1 I ESTIMATED OUANTTIY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> ..Hens ❑Yes ❑NO <br /> CUPAFORM(4199) Formerly SWRCS Form 13 <br />