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IF Rug 13 03 12:05p Ri16ard Thompson <br />925-2- 26-2050 p.6 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />�'� <br />UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br />0- pages per funk) <br />Pepe _ of _ <br />TYPE OF ACTU N ❑ I. NEW SITE PERMIT ❑4. AMENDED PFRMn' ® S. CHANGE OF INFORMATION) ❑6. TEMPORARY Srm CLOSURE <br />ICheek rut bene only) ❑7. PERMANENTLY CLOSED ON SITE <br />❑3. RENEWAL PERMIT -• ❑8. TANK REMOVED 430 <br />(.Specify reusan ..for lxal uw curly) (Spedfp change -fru krcvl use an7t) <br />BUSINESS NAME (Sane as FACILIWNAME oT DBA - Doing Business As) 3 <br />FACILITY ID # <br />1 <br />Circle K Stores, Inc. #2705446 <br />1 <br />8 <br />I <br />tj <br />I <br />L5CA'aOrjWITHNSI7EAJ),riona0 431 <br />1 } r <br />a <br />L TANK DESCRIPTION (A swiedplol pla+ with the kx=jm njrhe r.$7's)wm including buildings aml kmdmarlty shall be suMutred to the kxvl agency.) <br />TAANK1DO �j 432 <br />433 <br />TANKM NACTURFRff <br />COMPARTM£NTALMED TANK LJYoNo 434 <br />IfnYesD. compkteone page form <br />(^ <br />CZai � <br />DATE rNSiAWW (YEATLMO) 435 <br />TANK CAP QJTY IN GALLONS 436 <br />NUMBER OF COMPARTMENTS 437 <br />Ct <br />ADDITIONAL DESCRIPTION (hi)r kxul aw only) 438 <br />LL TANK CONTENTS <br />I TANK USE 439 <br />MOT(IR VEHICLE FUE[. <br />PETROLEUM TYPE 440 <br />❑ 1. REGULARUNLEADED ❑ 2. LEADED ❑ 5. JET FUEL. <br />jdeoried,eomPktcl'nrvkum7ypeJ <br />PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br />❑ 2. NON-FUELPETROLEUM <br />❑ la NIMPADEUNLEADED ❑ 4. GASOHOL ❑ 99. of IFR <br />❑ 3. CHEMICALPRODUC, <br />❑ 4. HkZARDOLS WASTE (7nc-h-kv <br />COMMON NAME (from Ho rd uav Maienak Inventory page) 441 <br />CAS # (from Hawrdan Aktenabr InwAl aq page) 442 <br />used al) <br />❑ 95. XERXES <br />DL TANK CONSTRUCTION <br />TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 413 <br />DOUBLE WALL EXT MOR MEMBRANE LINER []95. XERXES <br />��� <br />(('hick om item onfvJ ❑ 4. SINGLE WALL M A VAULT ❑ 99. OTHER .-- <br />TANK MATERIAL -prineary tank ❑1. BARE STEEL FIBERGLASS I PLASTIC ❑5. CONCRETE 095. XERXES 444 <br />ANOL ❑99. OTHER____ <br />8. RPCOMPATIBLEW/IOCtSLMETHi__,__ <br />E12. ST.AINLESSSIPI±J. 4. STEEL CLAD W/FIBTRGLASS [3s.F <br />((:.'heti ace item only) REINFORCED PLASTIC (FRP) <br />TANK MAT L•RIAI.-scconelay tank 01. BARE STEEL 3. FIBERGLASS/PLASTIC []S, FRP COMPATIBLE W/10016 METHANOL 095, XERXES 445 <br />❑2 STAINLESS STEEL❑4 STECL CLAD W/FIBERGLASS 09. FRP NON.CORRODIBLE JACKET []9A OTHER <br />(('hpcJ uric Nem adyJ REINFORCED PLASTIC (FRP) ❑10. COATEDSTEEL <br />❑ 5. CONCRETE <br />TA14KINTFRIORLINING ❑ 1. RUBBERLINED ❑3. EPDXYLINING ❑S CLASSLiNING ❑95. XERXES 446 DATELNSTALLED 447 <br />OR COATING ❑2. ALKYDLLNING ❑4. PHENOLICLINING - G UNLINED 099. OTHER----`_..--- <br />ICleerkarreircmmr CForlocaluse .1 <br />OTHER CORROSION ❑I. MANUFACTUREDFIBERGLASS REINFORCED PLASTIC 095. XERXES 448 DATE INSTALLED 449 <br />PROTECTION IFAPPLICABLE CATHODIC ❑4. IMPRFSSBDCURRENT ❑99. OTHER <br />PROTECTION <br />((,'heck nne;rem only) ❑2. SACRIFICIAL ANODE /!or (ornlresz rmluJ <br />SPILL. YEARTNSTALLFD 450 TYPE(fnrlxvlusconly) 451 <br />SPILL CONTAINMENT <br />OVERFILL PROTECTLONEQ MENTYEARINSTALLED 452 <br />❑1. ALARM FILL TUBE SHUCOFF VALVE U.N K.,(Chit# <br />off rlmu oPPI)'1 DROP TUBE �lU 1C.- <br />❑2. BALL FLOAT 4. XEMPT <br />STRIKER PLATE LU N ff <br />W. TANK LEAK DETECTION (i description ojlhe moeitoring program shall he svMullerl io the k=I agency.) <br />1F SINGLE WALL TANK (Check all char apply): 453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): 454 <br />❑I, VISUAL(EXPOSSED PORTION ONLY) ❑5. MANUAL TANK GAUGING(NITG) <br />❑1. VISUAL(SINGLEWALL IN VAIILTONLY) <br />❑2 AU[OMATICT.INKGAUGING(ATG) 06. VADOSE2ANECON"I7WWOusINTERSTmALMONITORING <br />03. CONTINUOUS ATG 07. GROUNDWATER <br />3. MANUALmoNTIORTNG <br />❑4. S'IATsTickLINVGNTORYRECONCILIATION(SIR)+ ❑8. TANKTETnNG <br />BIENNIAL TANK TESTING [199. OTHER <br />V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br />ESTIMATED DATE LAST USED (YIUMOID.AY) 455 <br />ESTIMATED QUANITIY OF SUBSTANCE REMAINING 456 <br />TANK FITTED WITH INERTMATERIAL? 457 <br />IJ Yes CJ No <br />( <br />