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22 v <br /> 411 <br /> UNIFIED PROGRAM CONSOLIDATED FOR <br /> 1�/by INKS , <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> f".O cages <br /> I <br /> TYPE CF ACTION t.NEw SITE PERMIT ❑ �. AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ 9 TE!APCPARY SITE CLOSURE <br /> ;Checr on.nem only) ❑ 7. PERMANENTLY CLCSEO CN SITE <br /> ❑3.RENEWAL PERMIT (Spocay reason-/or!ocal us.oruy) (Soeafy cnaAgo-•br local use only) ❑ 9. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACIUTY NAME Of OSA-Ooeq Busu+.ss As) FACUTY:0 e <br /> I i I d <br /> LOCATION WITHIN SITE(CP"040 431 <br /> L TANK DESCRIPTION <br /> TANK 10 s TANK MA UFAC COMPARTMENTALIZED TANK i Yes ❑ No <br /> K � e L C.�2 P e�U ,s*, Yes:Eon dere Dn �ya 0e9•for each wmoartinanl <br /> r <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS i <br /> W <br /> ADDITIONAL DESCRIPTION(Forlocal us.only) <br /> I - <br /> II.TANK CONTENTS <br /> TANK USE 432 �y PETROLEUM TYPE ❑ S.JET FUEL <br /> 1. MOTOR VEHICLE FUEL p ta. REGULAR UNLEADED C37- LEADED - <br /> (If marked,complete Petroleum 7yP.) ❑1p PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6.AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM [tc MIOGRAOEUNLEAOEO ❑ A. GASOHOL C3 99. OTHER <br /> ❑ 3. CHEMICAL PROCUCT CAS s(from Hazaeow.Matena/s Inventory page) .I <br /> COMMON NAME(hoot Naiardow Materis/s Irnenttuy page) <br /> ❑ 4. HA2AROOuS WASTE(Iridud.s <br /> Used 010 <br /> 1 N ` <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE`NALL ❑ 3. SINGLE WALLWITIi ❑ S. SINGLE WALL'MTH INTERNAL SLACCER SYSTEM <br /> (Check on.'tem any) Aff 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> T. .ATERIAL•onmyY lana � I. BARE STEEL ❑ 3. FIBERGLASS!PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check wertem any) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WMBERGLASS ❑ a. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ / BARE STEEL 03. FIBERGLASS I PLASTIC ❑ B. FRP COMPATIBLE Wmaa%METHANOL ❑95. UNKNOWN <br /> (Check ort.dom wW C32. STAINLESS STEEL a(,. STEEL CLAD W/FIB£AGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑III COATEw Si EEL <br /> ❑ 5. CONCRETE <br /> DATE INSTALLED <br /> TANK INTERIOR LINING C31. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5.G1A55 LINING ❑95. UNKNC+W4]3 <br /> OR COATING <br /> ❑ 2. ALKYO LINING ❑ A. PHENOLIC LINING ®5. UNLINED ❑99. OTHER (For local use only) <br /> (Check on.item onyt DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHOOIC W3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN A34 I <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (Far local us.Doty) <br /> (Cheek ons item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local us.only) OVERFILL PROTECTION ECUIPM ENT:YEAR INSTALLED <br /> (Check all that apply) Or 1. SPILL CONTAINMENT 2, B 1.ALARM Z22d O *3. FILL TUBE SHUT OFF VALVE Z=.�� f <br /> k2- DROP TUBE f f ❑ Z BALL FLOAT ❑ 4- EXEMPT <br /> 16 3. STRIKER PLATE tl <br /> N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Cheek All that ao ): IF pOUBLE WALL TANK OR TANK WITH BLACOER(Check one item <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VAOOSE ZONE ❑ 7 CONnNUOUS INTERSTTTLIL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 9. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99- OTHER <br /> V.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN PLACE <br /> ESTIMA TED CATE LAST USED(YR/MO/OAY) ESTIMATEO CUANTITY OF SUBSTANCE REMAINING 435 TANK FitL0 WITH INERT MATERIAL? <br /> gs4ons Cl Yes ❑No <br /> Formerly SNRCS Fom S <br /> CUPAFORM(4/99) <br />