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NIFIED PROGRAM CONSOLIDATED FORD PR H: UNDERGROUND STORAGE TANKS -TANK PAGE 1 AC#: (two pages per tank) TYPE OF ACTIONE] )NEW SITE PERMIT E] 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE Page 2 of 3 (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT X1 .8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 3 �05,3 LOCATION WITHIN SITE(optional) 4111- PHONE sPHONE I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 13J If"Yes",complete one page for each comparunent. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS a36 NUMBER OF COMPARTMENTS 4,7 ADDITIONAL DESCRIPTION(For local use only) 43,s IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE aa„ ❑ 1.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked co nplete Petmlcum Type) ❑ I b.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory Page) 441 CAS#(from Hazardous Materials Inventory page) ya, ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ L BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Check one item only) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑99,OTHER TANK MATERIAL-secondary tank ❑ L BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN aai (Check one item only) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I RUBBER LINED ❑ 3.EPDXY LINING E] 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 411 OR COATING (Check one item only) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99.OTHER (For local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION E](Check one iron only) 41MPRESSED CURRENT ❑ 99 OTHER ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use ady) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all dkar apply) ❑ I SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VAL' ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Chock one item may) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)