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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE I ((#o pages per lank) Page _... o1 TYPE OF ACTION ❑t.NEW SITE PERMIT ❑ 4. AMENDED PERMIT >�5. CHANGE OF INFORMATION} ❑ 0. TEMPORARY SITE CLOSURE (Check one item onW ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify mason-for local use curry) (Specify change.forlocal use only) ❑ S. TANK REMOVED 430 BUSINESS,/NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDS 1 g R. V f ?Lb+'- S.0-ytAJ G�S C41"', b I 61Ad LOCATION(3 THIN SITE .5, Q , ��C, • ! 9 a s Iy/y 3 S 4 [ -TANK DESCRIPTION TANK IDN TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes o ! 1 - � � i7 !f-Yei,complete one page for each compartmentDATE INSTALLED(YEARIMMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS I OM v V�Q ADDITIONAL DESCRIPT N(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE MOTOR VEHICLE FUEL 111. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (fr marked,compiv:*Pefroieum Type) El 1b PREMIUM UNLEADED DIESEL El6 AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM 1:1%.. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(fnclWas COMMON NAME(from Hazardous Afaleriah lmrntarypape) CAS 11(from Nuar>7ow Materials fninnfory pope) Used 04} III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3, SINGLE WALL W3TH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item eny) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑99- UNKNOWN Y ❑ 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check arra Rem orny) ❑ 2, STAINLESS STEEL ❑4. STEEL CLAD WfFIBERGLASS ❑ 9. FRP COMPATIBLE Wr100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 9. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN (Check an*Rom"JA ❑ 2. STAINLESS STEEL X STEEL CSD W)FtBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING E35. GLASS LINING 1395. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING A. UNLINED ❑99. OTHER Check arse Rem onF} � (For local use only) OTHER CORROSION IF OfI ❑ 1. MANUFACTURED CATHODICx-, 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT Q 99. OTHER (Check one item any) ❑ 2. SACRIFICIAL ANODE (ForlocaluseonlyJ SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use onW OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check Y Nat appy) ❑ ,. SPILL CONTASNM£NT ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE 2- BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE rV. TANK LEAK DETECTION IF SINGLE WALL TANK Check all that• ): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check crre itstm an ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTGJ ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE TONE JMQ. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINVOUSATG ❑ 7. GROUNDWATER © 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRRJOf0AY)) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WSTH INERT MATERIAL? 10/4- La c-&V.(-• patlons ❑Yes ❑No CUPAFORM(4199) * `_, Formerly SWRC8 Form B