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y. &FIED PROGRAM CONSOLIDATED FORM ^ TANK: Iry PR#: UNDERGROUND STORAGE TANKS -TANK ] r FAC#: (two pages per lank) TYPE OF ACTION Page 2 of3 ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Clank arty itan ony) ❑ ]PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT ❑8TANK REMOVED 430 BUSINESS NAME(S.as FACILITYNAME or DBA.Doing Business Aa) FACILITY ID: PR#: �J 1 LAZA a QLD -4 I p80 © 2 3 13 G LOCATION WrI IN SITE(opdooap r 431 PHONE 1.TANK DESCRI>FION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submincd to the local agency.) T1S'K n`# (`1a 412 TURER 411 COMPARTMENTALIZED TANK Yes No 434 1\ OD �Z 1�� TANK MANUFAC1("Ya".eonWkleoMPaBe farcxhwmPVMrnI C] ❑ VTE INSTALLED(YEAK/MO) 435 TANK CAPA ITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 �oo� ADDITIONAL DESCRIPTION(Fmioosl me ony) 438 I.TANK CONTENTS TANKUSE 439 PETROLEUM TYPE µ9 X1.MOTOR VEHICLE FUEL ❑ la REGULAR UNLEADED ❑ 2.LEADED ❑ S.JET FUEL (1[markW wmpktc Peholwan Type) ❑ Ib.PREMBM UNLEADED g3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ lc MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(aom Hawmm Mato ials lmm wge) µl CAS#(6om Hav Matoiab fvmtary page) El 4.HAZARDOUS WASTE µ2 (Includes Uacdoa) ❑ 95.UNKNOWN II.TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chalk ole item only) EXTERIOR MEMBRANE LINER [-195.UNKNOWN ❑ 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ I.BARE STEEL 3❑� H FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 4 (Cnmk one itam ❑ Iia'' only) 2.STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑ I.FRP COMPTIBLE W/IOW METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (C kom itcm 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 ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED µ7 OR COATING (awk one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑99.OTHER (Fm local me only) OTHERCORROSION ❑ I MANUFACTURING CATHODIC k3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN a9 DATE INSTALLED N9 PROTECTION IF APPLICABLE PROTECTION (Cnoe...iumony/ ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2SACRIFICW.ANODE (Forlrcal sue only) SPILL AND NY OVERFILL YEARINSTALLE450 TYPE(loctlummdy) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 k (Oio all out appy) 1 SPILL CONTAINMENT ❑ 1 ALARM e3 FILL TUBE SHUT OFF VAL` a21�a 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT 4� 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(Abe submitti m me looal agency.) IF SINGLE WALL TANK(LT kall that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 414 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check om non only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSEZONE ❑ I 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 TANKTESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL'? 457 E]Yes ❑No UPCF(12/99 revised)