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X07/25/2005 15:07 2094683433 EHD PAGE 02 <br /> UNIFIED)PROGRAM CONSOLIDA'T'ED FORM TANKS <br /> UNDERGROUND STORAGE TANKS -T` ffi oto pH *'I. r- gt5 per tank) <br /> TYPE OF ACTION ❑I NEW SITE PERMIT I! • AMENDED PERMIT ❑ 5 CH.kNbt OF TNFOIlUMATION O4 ,a <br /> ((Teck one Ilam only) (r,+�({ 4)9 <br /> ❑ 3 RENEWAL PERMIT (SP.xifyre.eon-forloealuaaonly) (Spatiryreason-forloeUomonly) ❑ 8 TANK RE MOVED <br /> amt, Fru[ILIJY NA.�IP or DBA-Doing Bmincm A6) FACILITY ID-. <br /> BUSINESS NAME(5 <br /> 431 <br /> LOCATION WITHIN SITE to ) / Q ' q5_3 <br /> u� <br /> I.TANK DESCRIPTION (A scaled plot plan with the oeacton of the UST ystem including buildings Bnd 1 marks/hall>x Submitted to the local eney) 43+ <br /> 432 TANK MANUFACTURER COMPARTMENTALIZED TANK Yes No <br /> TANK 1'D: ; ,,�- <br /> �. II•Yri,oamplete one pogc far each compartment. <br /> NUMMPARTMENTS 437 <br /> DATE RNSTALLED(YEA.R/MO) US A> C AC <br /> ash BER OF CO <br /> wR <br /> ADDIT(ONA. DESCRIPTION(rortoroluaco�tY) <br /> 11.7ANK CONTENTS <br /> dw <br /> K USE 4W PET EUM TYPE <br /> I. MOTOR VEHICLE FUEL Ip. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (Ifm,rkttteomplac►ewlrumYype) ly. PREMIUMUNLEADED ❑3. DIESEL '(3 6. AVIATION FUEL <br /> D 2.NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑a, GASOHOL ❑99.OTHER <br /> 4/2 <br /> D3.CHEMICAL PRODUCT COMMON NAME (lllom Hazvdoua hlaterialrinreatorypok-e) 441 CA #(fiom)laxudoua Mareriola ln•enWry P,ge) <br /> D 4. HAZARDOUS WASTE <br /> (Ineluda Uead Oil) <br /> D 95.UNKNOW'N <br /> 1[I. TANK CONSTRUCTION +a3 <br /> TYPE of TANK ). SINGLE WALL 3. SNNGLE WALL WITH Ll S.SINGLE WALL WITH TERIIAL GLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95.UNKNOWN <br /> (LTrck am ilrm only) <br /> z. DOUBLE WALL ❑a•StONLE WAIL IN VAULT O 99 OTHER 95. UNxNOWN T <br /> TANK MATERIAL-primpry t,nk 1. BARE STEEL 3. FIDERGLAS5 f PLASTIC 5.CONCRETE <br /> ❑4. STEEL CLAD W/FIBERGLASS D S.FRF COMPTIBLE W1100.1 METHANOL 0 99.OTHER <br /> (Cheek one ilemonly) 0 2. STAINLESS STEEL <br /> REINFORCED PLASTIC(FRP) <br /> FIBERGLASS 1 PLAS11 TIC S. CONCRETE <br /> 95. UNKNOWN d43 <br /> TANK MATERIAL-teeond,ry ua� 1.BARE STEEL <br /> (Cheekonoitcmonly) ❑ <br /> 2. STAINLESS STEEL ❑a. STEEL CLAD WIFIBERCLASS ❑1. FRP CO`rIPTIBLE Wll00We METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) e10.COATED STEEL <br /> ❑5. CONCRETE "7TANK)NTERIOR LINING 1.RUBBER LINED 3.EPO rY LINTNG S.OLASS LTNTNG 95.lfNKN <br /> 446 DATE INSTALLED <br /> OR COATING ❑Z ALKYD LIN NG0 4 PHENOLIC LINING ❑6 UNLINED ❑99 0 � \ (for local uae only) <br /> (Check one iltm only) dal DATE INSTALLED 449 <br /> OTHERCORROSION DINIANUFACTUREDCATHODIC ❑;i(VRESLASCURRENTREINFORCED PLASTIC [39s <br /> OTHER <br /> PROTECTION IF APPLICABLE PROTECTION (For local uxady) <br /> (Check one ism Daly) Dz SACRIFICIAL ANODE au <br /> aft OVERFILLPROTECTION EQLrIPMENT.YEARINSTALLED <br /> SPILL AND OVERFILL �j YEAR INSTALLED 450 TypL poc,l usranlr> <br /> (Check all that 31700 I PILL CONTAINNIENT 0' ❑3 FILL TUBE SHUT OFF VALVE <br /> .BALL FLOAT ❑4 EXEMPT <br /> 2DROPTUBE <br /> ir3 STRIKER PLATE <br /> IV.J ANK LEAK DETECTION(A deyenpeonorve-mitorirterminm dal)be e�6Nned to he IorataacneYJ <br /> d53 IF DOUBLE WALL TANK OR TANK WITH BLADDER dH <br /> IF SINGLE WALL TANK(CTrck,llthat apPly) (Check oncitcmordy) <br /> 0 1 VISUAL(EXPOSED PORTION ONLY) D 5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL M vAVLT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VAOOSE ZONE D IN <br /> 2 CONTUOUS WTERSTInAL MONrrORtNG <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER D 3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION O a TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> Iv.TALK CLOSURE INFOELMATI r PERMA-HENT CLOSURE IN PLACE uT <br /> 455 ESTIMATED QUANTITY DF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATEFJAL7 <br /> ESTIMATED DATE LAST USED(YIVMOlDAY) gallons ❑Yes ❑ No <br /> UT'CF(12/99 revised) 10 Formerly SWRCS Form B <br />