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jJa�,. 10 03 04: 47p Cie Brown (21 461-P34 1�5Ip . 2 <br /> UNIFIED PROGRAM COLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 CrWoP&gaPW*) <br /> Page-L-of-�L <br /> 6.T>MPORARY TANK CLOSURE 430. <br /> ❑ 4.AMENDED PERMIT ❑S.CHANGE OF INFORMATION ❑ y CLOSED ON SITE <br /> TYPE OF ACTION ❑ 1.NEW PEP.NG 1 ❑ 7-PERMANENTLY <br /> 3.R99EWALP£RMII (5 _,W) ❑ 8.TANK REMOVED <br /> (Check ooc ium only) 1. <br /> (spmfy rc"04) <br /> FACILITY CD. <br /> BUSINL-SSNAMEISam mFACRJYYNAMEorDIA-DoeT9Bus'll=$M) <br /> 431. <br /> LOCATION WITHIN S o08) i C- Tk 3 3 <br /> 1 7 E : ti7��va P � <br /> L TANK DESCRIPTION <br /> Planµwills the location of the UST system includin buildings and lantlmarl:s stall be stsbnritted to the]owl agency-} 434 <br /> (A scaled Plot 433. COWARTMENTALIZED TANK❑Ycs ■No <br /> ApI1:ID 11 O i13 3'T o 432. TANK MANUFACTURER fornchcom�ml. <br /> z._1 C 1f-ve4,-eomowooTx�t <br /> jv �� )\7 c w N N\Ca��� a36. NUMBER OF COMPARTMENTS 437, <br /> 435. TANK CAPACITY 1N GALLONS `1 <br /> DATE INSTALLED O I Y <br /> (YEARIMO) W /0 Cao G e--1 , 438. <br /> ADDITIONAL DLSCRJPTION(FoTlocal-emW) <br /> IL TANK CONTENT'S dd0. <br /> TANKUSE 439 PETROLEUM TYPE ❑5.JET FUEL <br /> 41 1.MOTOR VEMCLEFUEL ❑Ia.REGULARUNIEADED ❑2.LEADED <br /> [3❑3.DIESEL G. AVIATION GAS <br /> (](checked,oom9letereav".Type) *]b. PRFMIUM UNLEADEDGASOHOL ❑99.OTmR= 442. <br /> ❑ 2. NON-FUEL PETROLFUM ❑Ic.MIDG WX UNLEADED C]4- sat. CAS#(fiom lU d.Mat-U 1"e'WY paw) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(f.BW'dm A1dmi'R'vvcm mr <br /> ❑ 4. HAZARDOUS WASTE <br /> (1ndudes Used Oil) <br /> ❑ 95.UNKNOWN <br /> QI.TANK CONSTRUCTION M3. <br /> ❑]. SINGLE WAIS ❑3. SINGLE WALL WITHEXT£RIOR 5.SINGLE WALL WLTIIIN'iF11?IAL BLADDERSY.STEM <br /> TYPE OF TANK MEMBRANE LINER ❑95. UNKNOWN <br /> (Cbedc one item ouly) A.SINGE-WALL IN A VAULT ❑`)9. OTHER 95.UNTa10WN "4' <br /> 2-MM,DOIJBI.EWALL ❑ 5.CONCRETE <br /> TAN? MATERIAL-a^mm3' <br /> Tank 1.BARE 3-FIBERGLASS f PLASTIC _ <br /> ( one rccm ) ❑2.STAINLESS STEEL 4. STEEL CLAD WIFIBLRGLASS ❑8-FRP METI�TANN0L LE ❑99.OTI <br /> REINFORCED PLASTIC <br /> TANK I tAT£RNAL-secondvy twos 1. BARE STEEL D 3.FIBERGLASS I PLASTIC ❑8.FRP COMFITS?E W/70�"�METBANOL ❑95.CrrHERNKNOWN 445. <br /> (Cbct> one item poly) ❑2. STAIIQLESS STEF1 4•RrINFORCEDCLAD WPLASTIC(FRP) ❑0 COATER STEEI ABLE JACKET <br /> ❑99.TITHER <br /> 05. CONCRETE S.GLASS 95.UNKNOWNDATLIItSTALLED aa7- <br /> TANK INTEMPJ ED EP <br /> LINING 1.RUBBER LIN ❑3. OXY LINING ❑99.OTHER <br /> Q 2.ALKYD LINING ❑4.PHENOLIC LIND:G ❑G.UNI JNID <br /> OR COATING 449. DATE INSTALLED aa9. <br /> (beck one item od ❑99.OTHLSt`^-- <br /> OTBER CORROSION ❑L MANUFACTURED CAIlIODIC �a.UZRESFSM PLASTIC ❑95.1JNKI10 <br /> CURRENT <br /> pROTFCTION PROTECTION �, STALLED 452 <br /> ( cable ❑2.SACRIFICIAL ANODE sSl. OVERFII I,PROTECTION EQUR'MFSI T: <br /> Sl'II3 AND OVERFILL YEAR pISTALLE aso. T� ❑1.ALARM _�3.FILLE)M [USE SHITC OFF VALves <br /> S14U all the[apply) L 1.SPILL CONTAINMENT Q j�0 ❑2.BALL FLOAT ❑4.F 1 U'T <br /> S 3,STRIKER PLATE �a IV TANK LEAK DETECTION <br /> (A descri 'on ofthe monitoring program shall he sobmitLed to the local agcncY.) BLADDER 454. <br /> 453. DOUSES <br /> WALL TANK OR TANK WITH <br /> IF SINGLE WALL TANK (Check one item only) <br /> (heck all tbA apPIY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> (]1.VISUAL(EXPOSED FORTI ON ONLY) 2,CONTINUOUS INTERSTITIAL MONITORING <br /> []6.VADOSE ZONE <br /> 02.AUCOMATICTANK GAUGING(ATG) 0 7.GROUNDWATER ❑3.MANUAL MONITORING <br /> 0 3,CONTINUOUS ATG <br /> ❑4. STATISTICAL INVENTORY RECONCIl TAI ION 0 99T� TESTING <br /> OTHM �^ <br /> (SIR)+B�INIAL TANK TESTING CLOSURE IN PLAN' <br /> V.TANK CLOSIIRE INFORMATION I PERMANENT457. <br /> 4ss 456. TANK FILLED WITH INERT MATERIAL? <br /> BS IM,kTLD DATE LAST USED(YR/MOUAY) ESTIMATED <br /> QUANTITY OF SIIBSTANCE R£hfA1NDdG ❑Y� ❑ No <br /> gllous <br />