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FE'3-07-2001 WED 03:44 PM QUIK STOP MKTS INC FAX NO. 5106571544 V. U4 , <br /> ED PROGRAM CONSOLIDATED FqR TANKS <br /> UNDERGROUND STORAGE TANKS - TAN KPOAOGE 1 (two pages per tank) <br /> Pugo_Z_of 7.- <br /> SITE CLOSURE <br /> TYPE OP ACTION ❑1 NEW SrrE PERMIT ❑ 4 AMENDED PERMIT Q 5 CHANGE Or INFORMATION 8D TEMPO <br /> R �ENTLY CLOSED ON SITE <br /> (Chedt cna acm uNy) 8 TANK REMOVED 430 <br /> ❑ 3 R�NFWAL PERMIT (Specify rcn::an-for lord use only) (spoGly rc:.+san-for IoM use only) ❑ <br /> 1 <br /> BUSINESS NAMIi(-,7,r4 os FACILITY NAME or 08Apolnq dutinwxs AS)- 3 FACILITY ID: <br /> Quik Stop Market#132 •_ .�.- 431 <br /> LOCATION WITHIN SITE(optional) <br /> 1.7AN_K SCRlPT1oN (A sGalod plot plan with the Iot`BliUn of the UST system including buildings and landmarks shall be submitted lU lhct local <br /> anC .) 43a <br /> 432T/,�NK-MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No <br /> A KID# - if"Ye;",complete one pu9e for each companmen6 <br /> 4 Xerxes a0e �' <br /> A'f E <br /> INSTALLED <br /> A3`' TANK CAF"ACITY 1N GALLONS NUMBER OF COMPARTMENTS <br /> (YF-AR/MO) 10,000 1 <br /> 1991/Janua 436 <br /> AC)DITIONAL DESCRIPTION(For local use only) <br /> ►1-TANK CONTENTS <br /> 440 <br /> TANK USC 439 PETROLEUM TYPE <br /> JET FULL <br /> Ni MOTOR VEI•IICLE FUCI. ®13. REGULAR UNLFADED Q 2 LEADED ❑ <br /> 5. <br /> (itmorkud coavloln PotroleumType) ❑1b. PREMIUM UNLEADED Q3. DIESEL C]6, AVIATION FUEL <br /> _ <br /> d 2. NUN PUCE PETROLFUM Q 1c. MIDGRADE UNLEADED� ❑ 99.OTHER 4 GASOHOL © 442 <br /> 03, CI ICMICAL PRODUCT COMMON NAME prom rtazardous wteiials Irwontorypagc) 441 CASH(from II.zardoua MoIen61E Invanwry page) <br /> [�4. HA7ARDOUS WASTE Unleaded Gasoline Re Ular, 87 Octavo 8006-61-9 <br /> (Includes Used Ol) <br /> ❑95,UNKNOWN <br /> TANKOC NSTRUCTION <br /> NI':OF TAIJK - Q S• SINGLE WALL 3.SI GLEXTERIOR WAL MEMBRANE LINA 5D 5C UNKNOWNWITH 1-1- INTERNAL <br /> TYBLADDER SYSTEM 443 <br /> (Chuck one uem only) <br /> �2. DOUBLE WAIL C]4, SIGNLE WALL IN VAULT ❑99, OTHER_ 444 <br /> TANK M/1TCf1lAL-pnnw++y tank (]1, BARE STEEL ❑3. FIUERCLAS5//PLASTIC Y ❑5. CONCRETt± Q 9G. UNKNOWN <br /> (Check ono Ilc/m only) Q 2. STAINLESS STEEL 0 4. STEEL CLAD WlFI6ERGLASs 5. FRP COMPATIBLE W/ [199.OTHER <br /> REINFORCED PLASTIC(FRP) 100%METHANOL <br /> TANK MATERIAL_-;aconutYy unk Q 1. HARE S7ECL [33, FIBERGAS <br /> LS/PLAST'IC 5, CONCRETE 1395, UNKNOWN 445 <br /> (Chock one num only) Q 2. STAINLESS STEEL ❑4•TEL CLADD P/LASTIC(FRP) ® .W/1 00%METHANOL <br /> L COMPATIBLE [190, <br /> 90,OTHER <br /> R5INr <br /> Q 5. CONCF(ETE Q 10.COATED STEEL <br /> TANK IN(ERIOR LINING ❑1,RUBBER LINED I�3.EPDXY LINING Cl S,GLASS LINING 9.5.UNKNOWN 4aG PATE INSTAI-LED447 <br /> OR COATING 0 2 ALKYD LINING Ea 4 PI ILNOLIC LINING R8 UNLINED ❑09 OTHER (Fu•local use only) <br /> (Ohork onu Ilemonly) q40 PATE INSTALL ED 449 <br /> o fHF,R conROSION ❑1 MANUFAOTUNEC CAT110PIC Q 3 FIf,4Ef2GLASS.Ri INFORCED PLASTIC Q 95 UNKNOWN <br /> FROTCCTION IF APPLICABI E PROTECTION ❑4 IMPRESSED CURRENT Q 90 OTHER — (For local use only) <br /> (Cnrrk one Item only) p 2 SACRIFICIAL ANOOF _ 452 <br /> YEAR INS FALLED 450 TYPG(loc+l use a51 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL ANI)OVERFILL only) <br /> A SPILL CONTAINMENT�1 T' �993 ❑1 ALARM �3 FILL TUBE SHUT OFF VALVE <br /> (Check <br /> Out apply) 2 DROP TOPE � <br /> 1993 / rJ( E]2 BALL FLOAT Q 4 EXEMPT <br /> � <br /> 3 STRIKER PLATE `1991 qvj tP t ;;o <br /> —"' IV.TANK LEAK DETECTION(A d0.unpuon of the nwnuorinp prvg+cm shall bo suUmlted to the lord agency,) <br /> 454 <br /> 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLF WALL TANK(Checkoil tnitopply) 44Check oncilunonly) <br /> © 1 VISUAL(EXPOSED PORTION ONLY) Q 5 MANUAL TANK GAUGING(MTC) 0 1 VISUAL(SINGLE WALL 1N VAULT ONLY) <br /> ❑2 AUl OMATIC TANK GAUGING(ATG) []6 VADOSC ZONE ®2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ CONTINUOUS ATG 0 7 GROUNDWATER ❑3 MANUAL MONITORING <br /> (�4 STATISTICAL INVENTORY RECONCILIATION Q b TANK TESTING <br /> *(SIR) BIENNIAL TANK TESTING ❑99 OTHER _ <br /> -" IV,TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> n 4 ib ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> ESTIMATED DAl f LAST U„L,D(YRIMO/UAY) REMAINING <br /> Uformerly SW(�CB Form 5 <br /> PCF (1/99 revised) 9 <br /> 0 <br />