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UNI _. PROGRAM C.ON'SOLIDATEDFOR. TANKS / UNDERGROUND STORAGE TANKS-TANK PAGE 1 ( pages per a. ) Page t ❑ S.CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE AMENDED PERMIT ❑ 7. PERMANENTLY CLOSED ON SIT C3 8.TANK REM TYPE OF ACTION ❑1.NEW SITE PERMIT [34. Vl (J\ ($pedfychange.rorlocat use only) REMOVED a30 (Check one item only) ,�/ L�3.RENEWAL PERMIT (SpecAyreason•for local use only) FACILITY 10 0 v DBA• Doing Business As) BUSINESS NAME(Same as FACILITY NAME or -j- Cr r� MIA& 3 �3 ,31 LOCATION WITHIN SITE(Optional) I.TANK DESCRIPTION TAN Yes ❑ No COMPARTMENTAe ,,Plate one page for each compartment. TANK MANUFACTURER .,. If'Yes', TANK ID It /„&/%s SJ.C-� ��"Jc (.((,�//`� NUMBER OF C MP TMENTS S 5�9,5 TANK CAPACITY IN GALLBNS DATE INS TALLED(YEARIMO)q �r_Is©©4/ ` � l 0 ADDITIONAL 0 ESC IPTION(Forlxa!use nly) II.TANK CONTENTS PETROLEUM TYPE ❑ 5. JET FUEL TANK USE 432 ❑ 2. LEADED 0 g_ AVIATION FUEL ' MOTOR VEHICLE FUEL ❑,a REGULAR UNLEADED [1 3 DIESEL �{S PREMIUM UNLEADED C]99. OTHER (It marked.complete Petroleum Type) ❑ 4. GASOHOL ❑jr. MIDGRADE UNLEADED CASK(!om Haza dcus Materials Inventory page) ❑ 2. NON•FUEL PETROLEUM ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventorypage) ❑ 4 HAZARDOUS WASTE(Includes Used Oil) 111.TANK CONSTRUCTION ❑ ]. SINGLE WALL WTH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM TYPE OF TANK ❑ 1. SINGLE WAIL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER�. ❑95. UNKNOWN (Check one Item only) ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑99, OTHER____� TANK MATERIAL•P nary tank ❑ 1. BARE STEEL E4 STEEL CLAD WIF18ERGLASS ❑ 6. FRP COMPATIBLE W1100%METHANOL ❑ METHANOL 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) C]95. UNKNOWN (Clack one item only) ❑ 3. FIBERGLASS I PLASTIC ❑ 5. FRP COMPATIBLE WI100"•'e C]99. OTHER TANK MATERIAL-secondary tank C] 1. BARE STEELje4STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET (Check one item only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE DATE INSTALLED ❑ EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 6 UNLINED ❑99. OTHER�_- (For loco l use Only) TANK INTERIOR LINING C) 1, RUBBER LINED DATE INSTALLED OR COATING [3 4. PHENOLIC LINING ❑ 2.ALKYD LINING ❑95. UNKNOWN 434 (Check one item onl) ❑ 3. FIBERGLASS REINFORCED PLASTIC (For local use Only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 4 IMPRESSED CURRENT ❑99. OTHER��- PROTECTION IF APPLICABLE PROTECTION ) t:� ❑ 2. SACRIFICIAL ANODE For local use onry) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Chock one item on YEAR INSTALLED TYPE SPILL AND OVERFILL 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE (Check all that aPPhr) ❑ 1. SPILL CONTAINMENT ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 2. DROP TUBE �- ❑ 3. STRIKER PLATE - -' - iV.TANK LFAK DETECTION If DOUBLE WALL TANK OR TANK WITH BLADDER'Check one item only), IF SINGLE WALL TANK Check$11 that ep $ ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ' ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1, VISUAL(EXPOSED PORTION CONTINUOUS INTERSTITIAL MONITORING ❑ g VAOOSE ZONE ❑ 3. MANUAL MONITORING [3 2. AUTOMATIC TANK GAUGING(ATG) ATG) ❑ 7 GROUNDWATER ❑ 3. CONTINUOUSATG ❑ g. TANKTESTING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑99 OTHER BIENNIAL TANK TESTING d35 TANK FILLED VA7H INERT MATERIAL? V.TANK CLOSURE INFORMATION)PERMANENT CLOSURE IN PLA ESTIMATED QUANTITY OF SUBSTANCE REMAINING ❑Yes ❑NO ESTIMATED DATE LAST USED(YR)MOIDAY) gallons Formerly SWRC13 F CUPAFORM(4199)