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ww <br /> -ETN(FIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Pape <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE ' <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specily reason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS N (Sime as FACILITY NAME or D"-Doing Business As) FACILITY IDK 1 <br /> LOCATION IN SITE( 1 <br /> 1.TANK DESCRIPTION <br /> TANK 10 0 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> C I <br /> if Yes'.complete one page for each compartment. <br /> DATE INSTALLED(YEAR/M0) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocat use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> C11. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED C1 5. JET FUEL <br /> (if marked,complete Petroleum Type) ❑1D PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6 AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEAOED ❑ 4. GASOHOL ❑99 OTHER <br /> ❑ 3. CHEMICAL PRODUCT CAS a(from Hazardous Materials Inventory page) <br /> ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(ham Hazardous Materials Inventory page) <br /> Used Oio <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ S. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 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 LININGDATE INSTALLED <br /> OR COATING <br /> 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED ❑99. OTHER (For local use only) <br /> (Check one item on ) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Forlocal use only) <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item onl <br /> ❑ 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. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ 6. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> ��oa�3� ��?�D�ol <br /> CUPAFORM(4/99) • Formerly Stco.B <br />