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01108/2004- 08:23 2094683-4oq FIFTH FLOOR PAGE _9
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TS-TANIK PAGE 1
<br /> (7%vo p39-per tank)
<br /> ®r.a,
<br /> Pagc-of -
<br /> TYPE OF ACTION ❑ 1,NEW PERMIT ®4.AMENDED PERMIT ❑5.CHANGE OF INFORMATION ❑ &TEMPORARY TANK CLOSURE 4.10.
<br /> (Chink one item only) Q 3.RENEWAL PERMIT
<br /> ❑ 7.PERMANENTLY CLOSET)ONSITE
<br /> (SPEP ) (Specifytemon) ❑ 8.TANK REMOWD
<br /> BUSINESS NAME(Same m CACILtTY.NA&M wDOA-Doing Rusintm A.) 3. rc I LIN 11-71 1 .
<br /> l#GF�
<br /> LOCATION WITHIN SITE(optionol) Q:1
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<br /> TANK IA 432 TARN••IA�C b1AIV'UFACTURER 433. COMPARTMENTALIZED TANK Yea ] No.:
<br /> xTi�SF 5 If'W completeorepost lbreacbmropwtaiw.
<br /> DATE W§TALLKD 41s TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS _
<br /> (YEAR/MO) S,aod , 417.
<br /> ®no
<br /> 12, ova 2- c f (2,
<br /> ADDITIONAL DESCRIPTION 0 ar bell uw oniy) ,yy
<br /> 'li;a;t;;;:,m':px ::a'a:a -•I•x..'m::+. ...•; Gc;:..: Y� 1 ,,w.. - _ �:,..r:rn:: ..�..'
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<br /> : w , ...• �. .. .x nr,.:.......rri e,ixr:r:.s .:.• \ N.....:: ..:.... :. w,,, ���'.vrr.i.'..:.,•
<br /> TANK USE uv. PETROLEUM TYPE csa.
<br /> 91 1. MOTOR VEHICLE FUEL Q la.REGULAR UNLEADED ❑2. LEADED 5. SET FUEL
<br /> (Ifahacketl,eompktePewwotTypc) 1b.PREMIUM UNLEADBD [3 3. DIESEL ❑6. AYIATIONGAS
<br /> ❑ 2.NON-FUELPETROLEUM Ic.MIDGRADEUNLEADED 04. GASOHOL _
<br /> ❑99.OTElkR:
<br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(Itont H=xdom Matetnk inventory pop) 441• CASA 441
<br /> ❑ 4, tIAZARDOUS cVASTE
<br /> (Itcladcd ukd Oil)
<br /> ❑ 95.UNKNOWN
<br /> '.:4+,.,�:' ,1'�:b;ltM 19,?1t.e•t., tulr•:IJ,ta•l :\•tiGr'.._ _ .+�• '�'r�nl��'r' +,����•�y�r(-'�/'��{�'1ry*D�'}}'1$°$/'� a:[�,l:tr'A:;�.T'u'.f['Jil�i r: Bra M. �dnm.i: Ill.to l-.,, of\,ren
<br /> ill• fHdl ?rl'r •^HW i� ,..• �:fq ✓,YYN•\r M1°.a/.rRM�'IC�l.YF.T.'gVr.\6/17q.71"A�.V`Y R'BVi.r 6�! :.it/I•
<br /> f.INp ,t;' ".' f .y.�«.,...:�,.,..:..«,,..•.N:..... ':.]4:•r..G..,«..,.. «d,. .•-rvx•e,INH-. :�o-x.Hd#r�lii:.cG.mlr,.;{ti I I1::nHdw..r:1G. .,,}.,
<br /> TYPE OF TANK LI 1. SINGLE WALL 0 3. SINGLE WALL WITH EXTERIOR ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 14Q
<br /> (Check one item oa)y) MEMMRAKE LINER ❑95.UNKNOWN
<br /> 2.DOUBLE WALL 0.4. SINGLE WALL IN A VAULT ❑99. OTHER. _ _
<br /> TANK MATERIAL-preaary,em: 1.BARE STEEL 3.PIBERGLASS/PLASTIC 0 S.CONCRETE Q 95.UNKNOWNnd
<br /> ) a
<br /> (Cheek ax item oab) ❑2. STAINLESS STEM ❑t/_STEEL CLAD W/FIBERGLASS ❑S.FRP COMPATIBLE ❑99.OTHEA.;
<br /> REINFORCED PLASTIC W/100%METHANOL
<br /> TANK MATERIAL-wconcbxy,tank 1.BARE STEEL 3. FIBERGLASS/PLASTIC []S. FRP COMMIBLE W/100%METHANOL Ij 95.UNKNOWN47:.
<br /> (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9.FRP NON-CORRODA13LE JACKET ❑99.GTIIER
<br /> REINFORCED PLASTIC(FRP) ❑10. COATRD STEEL
<br /> 5.CONCRETE
<br /> TANK INTERIOR LINING E]):RUBBER LINED U 3.EPDXY.LR41NG U 5.GLASS LINING 0 95_UNKNOWN 446. DATE INSTALLED 447
<br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER
<br /> Check ow Item ott
<br /> OTHER CORROSION 01AL414UFACTUREDCATHODIC ❑3.FIBERGLASS REINFORCED PLA$TIC ❑95•UNKNOWN 44,4. DATE INSTP.I.LED 4m)
<br /> PROTECTION PROTECTION ®4.IMPRESSED CMINT ❑49.OTHER
<br /> licablc ❑2-SACRIFICIAL ANODE
<br /> SPILL AND OVERFILL YEAR INSTALLED 4Sa TYPE 4st, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED v 4SS
<br /> (Check all tlmt apply) 1.SPILL CONTAINMENT 04 1.ALARM _©3.FILL TUBE'HUT OFF VALVE
<br /> 2_DROP TUBE 2.BALL FLOAT _®4.EXEMPT
<br /> 3.STRIKER PLATE
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<br /> ,t :iNr.Mit•:"�)•I<#lid vy Y•k^ 1
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<br /> IF SINGLE WALL TANK 453• If DOUBLE WALL TANK OR TANK WITH BLADDER 454.
<br /> (Check all(bat apply) (Check one item only)
<br /> ❑I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MSG) ❑I_VISUAL(SINGLE WALL IN VAULT,ONLY)
<br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ®6.VADOSE ZONE ❑2,CONTINUOUS INTERSTITIAL MONTTI)RING
<br /> ❑S.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUALMONTIORING
<br /> ®4.STATISTICAL INVENTORY RECONCILIATION ❑&TANK TESTING
<br /> (SIR)+BIENNIAL TANK725MG ssXX 77II..e�'�G y�ty�❑99.OTHER
<br /> .rmNw.h•;t'N.vv.-1 w.t.ry;'r:.: :�:�T 'h�a,IQIw���JRaC+'. .:,., ...
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<br /> ESTIMATED DATE LAST USED(Yzm"AY) 455` ESTIMATED QUANT17 Y OF SUBSTANCE REMAIN WG N56. TANK FILLED WITH INERT MA17EPlALI
<br /> gtilc>� ❑Yel ❑No
<br /> UPCF hwfwre-b(1/99)-i/4 h4tp-//www.unidocswj Rev.02/16/00
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