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UNI PROGRAMCON-SOLIDATEDFORN. TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 ( ages pe t�(A <br /> Page <br /> ❑ 5.CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> ❑1.NEW SITE PERMIT ❑ !. AMENDED PERMIT <br /> ❑ 7. PERMANENTLY CLOSED ON SITE ��� <br /> TYPE OF ACTION ❑ a. TANK REMOVED 430 <br /> (Check one item only) �/ ($petrify chengs-for local use only) 1 <br /> I(�3.RENEWAL PERMIT (Speedy reason•for)oval use a+lY) <br /> FACILITY ID 0 y <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) ���� ; <br /> Fre A//x/� U_�T <br /> LOCATION WITHIN SITE(Optional) <br /> 431 <br /> I.TANK DESCRIPTION Oyes ❑ No <br /> TANK MANUFACTURER COMPARTMENTALIZED TANK <br /> If'Yai,complete one page for each compartment <br /> TANK IO e /+ � <br /> Q C� NUMBER F COMPA <br /> � (� NTS <br /> 6 � TANK CAPACITY IN GALLONS <br /> DATE INSTAL ED(YEAR/MO) ���Z . <br /> ADDITIONAL DESCRIPTION(Foflocal use only) <br /> It.TANK CONTENTS <br /> 432 PETROLEUM TYPE ❑ 2 LEADED ❑ 5 JET FUEL <br /> � TANK USE p 5. AVIATION FUEL <br /> K1 MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑ 3 DIESEL <br /> ❑ <br /> ❑1b. PREMIUM UNLEADED 99. OTHER <br /> (II marked.complete Potroleum Type) [3 4. GASOHOL <br /> ❑ 2. NON-FUEL PETROLEUM URI., MIDGRADE UNLEADED CAS It(lrom Hazardous Materials Inventory page) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) <br /> ❑ 4. HAZAROOUS WASTE(Includes <br /> Used Or9 <br /> III.TANK CONSTRUCTION <br /> ❑ 3. SINGLE WALL VYITH ❑ S. SINGLE WALL VJ1TH INTERNAL BLADDER SYSTEM <br /> TYPE OF TANK ❑ SINGLE WALL EXTERIOR MEMBRANE LINER ❑95_ UNKNOWN <br /> DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> (Check one+tem only) ❑95. UNKNOWN <br /> ❑ 3, FIBERGLASS I PLASTIC ❑ 5. CONCRETE <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL �rSTEEL CLAD W/FIBERGLASS ❑ 8 FRP COMPATIBLEW1100%METHANOL C3 99. OTHER---- <br /> (Check one dem only) <br /> ❑ 2, STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑95. UNKNOWN <br /> ❑ 3. FIBERGLASS/PLASTIC ❑ & FRP COMPATIBLE WILE J METHANOL ❑99 OTHER__-- <br /> TANK MATERIAL-secondary tank ❑ J. BARE STEEL ,,.,/ ❑ 9. FRP NON-CORRODIBLE ACKET <br /> 4. STEEL CLAD WIFIBERGLASS <br /> (Check one item only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) (3 10 COATED STEEL <br /> ❑ S. CONCRETE OATEINSTALLED <br /> ❑ 3. EPDXY LINING ❑ 5. GLASS LINING C]95. UNKNOWN433 - <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 6 UNLINED ❑99. OTHER (For local <br /> OR COATING ❑ 4. PHENOLIC LINING DATE INSTALLED <br /> ❑ 2. ALKYD LINING ❑95. UNKNOWN 434 <br /> (Check one item On 3. FIBERGLASS REINFORCED PLASTIC _- (Forloca� <br /> OTHER CORROSION C] 1, MANUFACTURED CATHODIC ❑99. OTHER <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ^ <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED C�L71 <br /> YEAR INSTALLED <br /> SPILL AND OVERFILL i. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> (Check all that apply) ❑ 1. SPILL CONTAINMENT_�- ❑ 4. EXEMPT <br /> ❑ 2. BALL FLOAT <br /> ❑ 2. DROP TUBE - <br /> ❑ 3. STRIKER PLATE <br /> IV,TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER'Check one item onl <br /> IF SINGLE WALL TANK Cheek eh that a ): ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 5. MANUAL TANK GAUGING(MTG) 2-1 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ a VADOSE ZONE <br /> ❑ 3. MANUAL MONITORING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER <br /> ❑ 3. CONTINUOUS ATG <br /> ❑ 8. TANK TESTING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑99 OTHER <br /> BIENNIAL TANK TESTING <br /> V.TANK CLOSURE INFORMATION IPERMANENT CLOSURE IN PLAC TANK FILLED WITH INERT MATERIAL'? <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING ❑No <br /> ESTIMATED DATE LAST USED(YR/I.tOIDAY) gallons ❑Yes <br /> Formerly SWRC13 Fc <br /> CUPAFORM(4)99) <br />