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FIED PROGRAM CONSOLIDATED FORM* 1 r? 0 TANK: 1 PR#' UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: Ov (two pages per tank) Page 2 ora TYPE OF ACTION ❑ INEW SITE PERMIT ❑4AMENDED PERMIT ❑ S CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chak only itemmly) �- ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT ❑STANK REMOVED 439 BUSINESS NAME FACILITYNAME or DBA-Doins Bmi ") FACILITY ID: PR#: �2 3 1 aLAZa �Q� � A 0 2 1 <J 5 LOCATION WITHIN SITE(opdm o bpp 431 PHONE7p9 3t.$o12-I 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.) T 1D#Q D� ' A ' 432 TANK MANUFACTURER 433COMPARTMENTALIZED TANK [I Yes ❑No 434 !J -l. trNa".mrrylaeonepageforeecM1mvgarnnml TE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(For loaf me only) 439 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 1.MOTOR VEHICLE FUEL MI.REGULAR UNLEADED ❑2.LEADED ❑ 5.JET FUEL ofm cdmvgdea Pctrolam Typo) i lb.PREMIUM UNLEADED !'DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(Oom Hazadmu Maunrb lme yass) 441 CAS#(Gum Hazardous Mmmois lme r r,page) 442 ❑4.HAZARDOUS WASTE OmJuaa Used Od) ❑ 95.UNKNOWN ID.TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM Us (Chockamitmonly) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN g2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (CTakom item only) ❑2.STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary lank ❑ 1.BARE STEEL W3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE [:195.UNKNOWN 445 (Chakom item only) ❑ 2.STAINLESS STEEL 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED H7 ORCOATING (Chakmm item only) ❑2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑6 UNLINED ❑ 99.OTHER (Pmlmal aaeauy) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC E 3 FIBERGLASS REINFORCED PLASTIC [:195 UNKNOWN 449 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION 4�l (Chakomitemonly) E] 4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 25ACRIFICIAL ANODE (Pm loal me only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(loaloamly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 K1 SPILL CONTAINMENT (Gak all wt apply) ❑ 1 ALARM e3 FILL TUBE SHUT OFF NAL` b<2 DROP TUBE ❑ 2BALL ❑ 4EXEMPT M'3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A dmaipdon o9we mooilooin,,.,-rioube abmindm uKl«al.sa y.) IF SINGLE WAIL TANK(CTak all shat appy) 453 IF DOUBLE WALL TANK ORTANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Ch^'k ooe nem only) ❑2AUTOMATIC TANK GAUGING(ATG) ❑ 6VADOSE ZONE ❑�..�/ 1 VISUAL(SINGLE WALL IN VAULT ONLY) F-13 CONTINUOUS ATG El GROUNDWATER �2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK 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 ESTIMATEDQUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑ No UPCF(12/99 revised)