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1-7.. <br /> q_ <br /> _. UNgIFD PROGRAM CONSOLIDATED FORM I <br /> TANKS 1 <br /> UNDERGROUND STORAGE TANKS -TANK a 3 03cTw°pages per tank) <br /> ii Page of <br /> F CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 4y0 <br /> A <br /> F-- <br /> 2 <br /> O ❑ 4 AMENDED PERMIT' <br /> � ❑ 7:PERINAIZEtSILY CLOSED ON 51T1: <br /> TYPE OF ACTION ❑ i.NEW PERIu[IT <br /> NEWAL PERMIT ❑ 9,TANK REMOVED <br /> (Uerkaae <br /> item only} ❑ 3.RE (SP-ify Ic 1) (Specify reason) .. 1. <br /> FACILITY lO: n O h b <br /> BIISiNES$t3AME(sea:=�sFACajTYs+u�tEay.AEA-noing9us+nr�ns) 431. <br /> LOCATIO WIT I QN ITE(option d) C-)p q 5 <br /> O L TANK DESCRIPTION <br /> s shall be submitted to the local agency_) �� <br /> 1 (A scaled plot plan with the location of the UST system including buildings and33.. Q ARTMENTALLZ TANK ❑Yes No <br /> aye. TANK MANUFACTURER <br /> If, TANK 1D lf'Yes,'comPletc one page fortach wmA�W+tet. <br /> p bo y tjoclf�, C-0 1, �' 436. NUMBER OF COMPARTMENTS 437. <br /> 435. TANK CAPACITY IN GALLONS <br /> DATE INSTALL.EI) <br /> (YEARIMO) 438. <br /> ADDITIONAL DESCRIPTION(For low ase O0W , <br /> i <br /> II.TANK CONTENTS 440 <br /> 6 439. PETROLEUM TYPE <br /> h <br /> TANKUSE ❑5. JET FUEL® 1. MOTOR VEHICLE FUEL ❑Ib ❑2. LEADED t <br /> REGULAR UNLEADED 3. DIESEL, ❑6. AVIATION GAS <br /> (If rbccte$complere PGroSwm Type) PRI.MILIM UNLEADED ❑99.OTFIF.R: <br /> EUNLEADF-D ❑4. GASOHQL °'r'- <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRAD 441. CASfI(from I;R�rdeus Mater alsinw tory Pere} d <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(from H' dO s ma'c"`loventaty Pte) <br /> ' p 4. HAZARDOUS WASTE <br /> (tncbdd Uscd oil) . <br /> ❑ <br /> 95,UNKNOWN <br /> TANKCONSTRUCTION- Ai,BLADDERsrsTEM 443. <br /> NGLE WALL WiTHEXI'ERIOR <br /> C] 3. SI <br /> ❑5. SINGLE WALL WTTHTNTI RN <br /> TYPE OF TANK 1.SINGLE WALL ❑ MEMBRANE LIIIEIt ❑95. UNKNOWN <br /> 1 (Check one item only) 95.UNKNOWN <br /> ®2.DOUBLE WALL ❑4. SINGLE ww IN A VAUL444. <br /> T ❑99.CO I1ER- <br /> FRP <br /> TANK MATERIAL-P^rn�uak <br /> L BARE STEEL 3.FIBERGLASS 1 PLASTIC <br /> ❑2. STAINLESS STEF ❑4_ STEEL CLAD W/MREN ORCED P TIC S ❑S W11Do°O/MFTHANOL ❑99.OTHER: aas. <br /> (Cbl MC item only) 6.FRP COb)p TIBLE WIItN)%METHANOL ❑95.UNKNOWN <br /> ' TANK MATERIAL-secon' tmk ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑ RP <br /> Check one item only) ❑2. STAQILF•SS STEEL[14. STEEL LAD WIFIBERGLASS 13 CED PLASTIC(}-RP) ❑90 <br /> FLOATED STEEL DABLE JACI:ET [I 99.OTHER <br /> { <br /> ❑5. CONCRETE 95 UNKNOWN a46. DATE INSTALLED 447. <br /> 1.RUBBER LINED 3.EPDXY LWING 5.GLA55 LINING <br /> TAMC INTERIOR L�IING ❑99.OTHER___�- <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC 1-II31NG ❑6.UNLW£D 4i8 DATE II fSTALL£D . <br /> Check one item onl ACII)RED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN <br /> OTHER CORROSION ❑i.MANUF ❑4.UI(PRESSED CURRENT ❑99.OTHER <br /> PROTECTION PROTECTION YEAR INSTALLED asZ. <br /> licable ❑2.SACRMCIAL ANODE 450TYPE a51. OVERFILL PROfECTTON®IKEMPT E SlI11T OFF VALVE t'i-D <br /> YEAR INSTALLED <br /> SPILL AND OVERFIL -C',3 <br /> ❑2 qI gLOAT� ❑4.EXEMPT <br /> (Checkall that apply) ®1.SPILL CONTAINMENT '.� <br /> tB 2.DROP TUBE 6 �� <br /> 99 3.STRIKER PLA1 E✓ W TANK DETECTION. = <br /> shall be submitted to the local agency.) WITIi BLADDER454. <br /> (A description of the monitoring Program a53. IF DOUBLE WALL TANK 5R-1 <br /> IF S(NGLE WALL TANK (Check one item only) <br /> (Check all that aPPIY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 1.VISUAL(EXPOSED PORTION ONLY) ❑6.VADOSE ZONE <br /> ®2.CONnINtIOUSINTERSTITIALMONJTORING <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> 3.CONTINUOUS ATG <br /> [34.STATISTICAL INVENTORY RECONCILIATION. ❑S.TANK TESTING <br /> ❑99. OTHER <br /> (sut)+BTENNIALTAI3KTE57ING TION/ PERMANENT CLOSURE IN PL ?ACE • 457. <br /> V.TANK CLOSURE P �OgI G 456. TANK FILLED WT1T1 nIERT MATERIAL <br /> aSs ESTIMATED QUANTI fY OF SUBSTANCE REMAININ ❑Yes ❑ Na <br /> TiMATED DATE LAST USED('I �' gA.ms <br />