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UNIFIED PROGRAM CONSO1IDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (t—pages pe,rank) Page TYPE OF ACTION U' , .EW SITE PERMIT ❑ a AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION) ❑ E. TEMPORARY SITE CLOSURE (Check one.tem only) En 1. PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT (Spocy Mason-for local use only) (Speorfy change-for local use only) ❑ f!. TANK REMOVED 430 O l BUSINESS NAME(Same as FACILITY NAME or DBA-Domg Bus"ss As) FACILITY IDR 1 Lws 6()yUj 5�,.� ZZ3 oDIJ-IQSzI LOCATION WITHIN SITE(OP00 .Q,}_. 431 - y' 05-1y I.TANK DESCRIPTION TANK 109 TANK MANUFACTURER COMPARTMENTALIZED TANK B Yes ❑ No If-Yei,complete one page for each compartment DATE INSTALLED(YEARlMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS Gkj 2 6,oho- K IZ(C SIA 1w0 ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE L7 t MOTOR VEHICLE FUEL to REGULAR UNLEADED g K ❑ 2_ LEADED ❑ S JET FUEL (If maned,complete Petroleum Type) ❑to PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6 AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑Ir MIDGRADE UNLEADED ❑ a_ GASOHOL ❑99 OTHER ❑ 3 CHEMICAL PRODUCTGAS a(IMM Hazardous Mafenals InNntory page) COMMON NAME(hom Hala/ddua MSNnals InNntory page) ❑ ! HAZARDOUS WASTE(Includes ^ kl n Used OrQ (1/` 'C &U6104 �J AL1 III.TANK CONSTRUCTION TYPE OF TANK ❑ 1 INGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95 UNKNOWN (Check one nem only) 2 DOUBLE WALL ❑ A, SINGLE WALL IN A VAULT �� ❑99. OTHER TANK MATERIAL-PnmarY tankBARE STEEL ❑ 3. FIBERGLASS/PLASTIC C35 CONCRETE ❑95 UNKNOWN 1 (Check one item only) C3 2. STAINLESS STEEL C3e. STEEL CIAO W/FIBERGLASS ❑ S FRP COMPATIBLE WfI00%METHANOL C199. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary Lank ❑ 1 BARE STEEL ❑ ] ERGLASS I PLASTIC [:1E. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one dem only) ❑ 2. STAINLESS STEEL �. STEEL CLAD W/FIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE DATEINSTALLEO TANK INTERIOR LINING ❑ 1_ RUBBER LINED ❑ 3. EPDXY LINING - [35 GLASS LINING C:195. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ a. PHENOLIC LINING 6 UNLINED C:1 99 OTHER (For local use Only) (Check one nem on ) DATE INSTALLED OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN e34 PROTECTION IF APPLICABLE PROTECTION a. IMPRESSED gUR ENT 99 OTHER (Fa local use only! (Check one nem only) L�I 2. SACRIFICIAL ANODE V b~ SPILL AND OVERFILL YEAR INSTALLED TYPE(For local •only) OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED (Check all that apply) 1. SPILL CONTAINMENT W 0 11. ALARM O❑ ] FILL TUBE SHUT OFF VALVE � // BALL FLOAT OC�a EXEMPT .L�7 DROP TUBE L7/Z.]. STRIKER PLATE CI 66O N. TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK HATH BLADDER C ock one Mm 0 ). IF SINGLE WALL TANK Check 00 that• ) . ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) �{❑�/I VISUAL(SINGLE WALL IN VAULT ONLY) . C1 2. AUTOMATIC TANK GAUGING(ATG) ❑ fl. VAOOSE ZONE LY 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 7. GROUNDWATER ❑ ]. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ a. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ E. TANK TESTING BIENNIAL TANK TESTING ❑99 OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE UST USED(YR/MQ/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? - gallons ❑Yes ❑No 512,1 10 tD/z//� Formerty SWRCS Form B CUPAFORM(4199) D��7/tel