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D �I moo 7v,. a• PROGRAM CONSOLEDATED UNDERGROUNDKS STORAGE TANKS- PAGE 1 Zn- Page_of- TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Speefyreason-forlocatuse oWy) (Specify reason-forlocaluseonty) ❑ STANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME.DBA-Doing Business As) 3 FACILITY ID: _ 1 SBC#ESCLCAI l - =-• LOCATION WITHIN SITE(optional) - 431 L TANK 7DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 1 Modem If"Yes,completeonepageforeachcompartment DATE INSTALLED(YEARNO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 12004 ),000 ADDITIONAL DESCRIPTION(For local use only) 43s IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE, 440 L MOTOR VEHICLE FUEL ❑la. REGULARUNLEADED ❑2. LEADED ❑5. TET FUEL (Ifrnarked complde Petoleum Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER - 0 3. CHEMICAL PRODUCT COMMON NAME(from Harmdow Materials lnventorypaga) 441 CAS#(from Hwwdoos Matteuaals Inventory page) 442 ❑4. HAZARDOUS WASTE Oncludes Used Oil) ❑95.UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH DnERNAL BLADDER SYSTEM 443 (Checkoneitern only) EXTERIOR MEMBRANE LIVER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER_ TANKMATERSAL-pimarytank 1.BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444 (Check oneAem only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FFIBERGLASS 0 S.FRP COMnIBLE W/lo0%METHANOL ❑99.OTHBR REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank I.BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95.-UN KNOWN 445 (Checkmeitem ordy) ❑2. STAINLESS STEEL N 4. STEEL CLAD W/FB3ERGLASS 138. FRP COMPTB3LE W/100'/a METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 13I.RUBBEgLlNED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING, ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one ft=only) (For loaf use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44s 448 PROTECTION IFAPPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(locd use only) 451 OVERFILL PROTECTION EQUIPMENT-YEAR INSTALLED 452 - (Check all that apply) ®I SPILL CONTAINMENT 2004 ®] ALARM 2004 0 3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE 2004 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 2004 IV.TANK LEAK DETECTION(Adse4)6onofthemorawmgprogremshallbesubm nedtothelowl agency.) IF SINGLE WALL,TANK(check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING (Check one item only) (MIG) ❑i VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE H 2 CONTINUOUS zNrERSTiT IAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL moNITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑STANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE IN-FORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED bVITII INERT MATERIAL? 457 gallons 0 Yes 0 No