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UNIFIED PROGRAM CONSOLIDATED FORMTANKS 2 I.. OR UNDERGROUND STAGE TANKS _ TANK PAGi 1 `� TYPE OF ACTION (Two pages per tank) ❑ 1.NEW PERMIT (Check one item only) ® 3.RENEWAL PERMIT CHANGE OF INFORMATION 13 4. ENDED PERMIT ❑ S. Page_of - ❑ 6.TEMPORARY TANK CLOSURE BUSINESS NAME s (specifY mzon) ❑ 7.PERMANENTLY 430. ( ameaz FACILITY NAME or DBA_ (specify reason) CLOSED ON SITE R der Trans ortation Services gau Inas As) 3. FACILITY ID: ❑ 8.TANK REMOVED LOCATION WITHIN SITE(ppnonal) #1071 3633 Duck Creek Drive 43I TANK ID# (A seed plot plan withI.TANK DESCRIPTION the location of the UST 43z system including buildings and landmarks shall be submitted to the local agency,) 1 � � TANK MANUFACTURER Trusco 413 COMPARTMENTALIZED TANK DATE STALLED �yes No 434 (YEAR/h40) 435. TANK CAPACITY IN GALLONS vyva••m ine one n'p page For each ro^Wanmem 10/31/1990 4J6' NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(F laal,sseon2,000 - 4 439. TANK USE 439 II. TANK CONTENTS 111. MOTOR VEHICLE FUEL PETROLEUM TYPE ❑ la. REGULAR UNLEADED (Irchak eq cor�lne Pewkam Type) ❑2. LEADED ❑5. JET FUEL 440. ❑ 2. NON-FUEL PETROLEUM El IPREMIUM UNLEADED ❑3. DIESEL 13 Ic. MIDGRADE UNLEADED 6. AVIATION GAS ❑ 3. RAZARCHEMIPRODUCT COMMON NAME Cl❑4. GASOHOL 99.OTHER; 5z6 42A, L ® 4. HAZARDOO US WA$TE ( H� Materiels Inventory page) at CAS#(Gom Heardous Meienals Inventory page 42,(IaWea Uses Oil) Used Oil ) ❑ 95.UNKNOWN TYPE OFTANK III. TANK CONSTRUCTION ❑1. SINGLE WAIL (Chale one item only) ❑3. SINGLE WgLL WITH EXTERIOR ❑5. SINGLE.WALL WITH INTERNAL BLADDER SYSTEM 443. ®2. DOUDLE WALL MEMBRANE LINER ❑95. UNKNOWN TANK MATERIAL-prvtvyunk ❑1, gARgS��, ❑q. SINGLE WgLL INA VAULT ❑99. OTHER ®3. F®ERGLASS/PLASTIC ❑5. CONCRETE (Chet one item only) ❑2. SFAMLFSS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑95.UNKNOWN µq, REINFORCED PLASTIC FRP ❑8. FRP COMPATIBLE ❑99.OTHER: TANK MATERIAL-saosilary t��h ❑I, gpltE SI¢y ®3. FIBERGLASS/PLASTIC W/ISA METHANOL (Click ane item only) ❑2, ❑8. FRP COMPTIBLE W/100^%METHANOL ❑95.UNKNOWN 445. A1NL.FSS STEEL❑q. STEEL CLAD W/FBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL TANK INTERIOR LINMG ❑1.RUBBER LINED ❑5. CONCRETE OR COATING ❑2.ALKYD LINING ❑3 EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. Check one item only) ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.DTIIER OTHER CORROSION ❑1,MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC PIfAROTECTION PROTECTION ❑95.UNKNOWN 44a. DATE INSTALLED 449. SPILL liND ❑2.SACRIFICIAL ANODE ❑4.IMPRESSED CURRENT Q 99.OTHER SPILL AN Dapply)OVERFILL _1990YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION (Check all that apply) ® I.SPILL CONTAINMENT 1990 EQUIPMENT: YEAR INSTALLED 452. ❑2.DROP TUBE L ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑3.STRIKER PLATE 2.BALL FLOAT_ ❑4.EXEMPT -" IV.TANK LEAK DETECTION IF SINGLE WALL TANK (A description of the monitoring program shall be submitted to the local agency.) (Check all that apply) 45a IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING MTG (Check one item only) ❑2. AUTOMATIC TANK GAUGING(ATG) ( ) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑3. CONTINUOUS ATG ❑6'VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑I.TANKTESTING (SIR)+BIENNIAL TANK TESTING 1199. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE C1�1�1�11M'��'��gE��{�, IM) 455 E$T1MAfEpQUANfTTtOFSusSThrtCEFsana�Tno 4M rANKYLLC➢WT INCRTMATERALT 431 GJ�u�� PAM QYea No Rev.02116/00 Wpp.onidocs.org