Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM fOlfD UZ <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> V ) (f^'�FaS'sCcrtarij I <br /> III w✓�5 / Page <br /> TYPE OF ACTION ❑1.NEN SITE PERMIT ❑ 1.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSURE <br /> C3(Check ane item only) 7. PERMANENTLY CLOSED ON SITE - <br /> ❑3.RENEWAL PERMIT (SpsI Mason-tor local use urj) (Spent/Charge-tor local use a ❑ p, TANK REMOVED 430 ---'---- <br /> FACILITY <br /> BUSINESS NAME(Same as FACILITY NAME or 08A•Oclrq 8winess As) <br /> .r. ••F <br /> V <br /> LOCATION WITHIN SITE(O;::naq 431 <br /> L TANK DESCRIPTION <br /> NK 10 a TANK MANUFACTURER COMPARTMENTALIZED TANK C1 Yes No <br /> TANK ch 10`nom I(, If es'•Complete ane page kr eaCamparr.e.^.t <br /> 7CWTANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(Y EAR,MO) � <br /> AOOITIONAL DESCRIPAON(?or local use any) - <br /> B.TANK CONTENTS <br /> TANK USP 432 PETROLEUM TYPE <br /> S <br /> ❑ 2. LEADED ❑ . JET FUEL <br /> t.MOTOR VEHICLE FUEL 1a REG 5. <br /> UNLEADED ❑ 0.AVIATION FUEL - <br /> (itmadd•complete PNYM411I Type) ❑ip PREMIUM UNLEADED ❑ 3. DIESEL <br /> ❑ I. NON-FUEL PETROLEUM EI 4. GASOHOL ❑99. OTHER <br /> ❑1c MIOGRAOE UNLEADED <br /> ❑ 3.CHEMICAL PROCUCT ) CAS a(from Haza dons Matenals Inventory pa;e) I <br /> COMMON NAME III Hazardous Matertals In7.+ntory P 9 a e <br /> ❑ 4. HAZARDOUS WAST:(Includes <br /> Used 01 <br /> N <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ t NGLE WALL ❑ 3..SINGLE WALLWATH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER [195, UNKNOWN <br /> (Check one dem only) 2. DOUBLE WALL '❑ 4. SIN LE WALL IN A VAULT <br /> ❑94. OTHER <br /> ❑95 <br /> TANK MATERIAL•PI taro /. BARE STEEL 3. FIB ERGLASS I PLASTIC ❑ S. CONCRETE . UNKNOWN <br /> ❑ <br /> (Check one dem oaty) ❑ 2. STAINLESS STEEL ❑ ♦ STE= LAO WIFIBERGLASS ❑ S. FRP CCMPATIBLE WIICOY.METHANOL ❑99 OTHER _ <br /> _NFORCED PLASTIC(FRP) <br /> TANK MATERIAL•$eCa+oary taro ❑ t BARE STEEL 3 FIBERGLASS I PLASTIC ❑ e_ FRP COMPATIBLE WI1CO%METHANOL ❑95. UNK.NO71ATt <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CUD WIFISERGLA S' ❑ 9. FRP MCN_CORROOIBLE JACKET Cl 99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> '•'❑ S CONCR_RE <br /> GATE INSTALLED -. <br /> TANK INTERIOR LINING ❑ 3. EPDXY LINING El 5. GLASS LINING El 9S. UNKNOWN433 <br /> OR COATING ❑ 1. RUBBER LINED <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ S. UNLINED ❑99. OTHER (For local use an ) ' <br /> (Oheck are dem on 1 PATE INSTALLED <br /> OTHER CORROSION434 <br /> PROTECTION IFA➢PUU3_E ❑ /. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN . <br /> PROTECTION ❑ 4 IMPR=SSEOCURFE.4T ❑99. OTHER (two,rocaruse on;y! <br /> (Check one"Al OAh1) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL ' <br /> -- YEAR INSTALLED TYPE(For local use only) OVERFILLPROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that aptly) 1 LL CONTAINMENT 1.A 3. FILLTUSE SHUT OFF VALVE <br /> 2�9¢IP TUBE 2 9ALL FLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> TV.TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK 77TH BLADDER(Check one item OPAL <br /> IF SINGLE WALL TANK(Check alt Nat aC )' <br /> C]t UAL(EXPOSED PORTION ONLY) <br /> S. MANUAL TANK GAUGING(MTG) ❑ t. VI AL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 6. VAOOSE ZONE CONTINUCUS INTERSTITIAL MONITORING <br /> UTCMATIC TANK GAUGING(ATG) ❑ 3, MANUAL MONITO RING <br /> 3. t1TINU'OIISATG ❑ 7. GROUNVNATER <br /> ❑ 4. STATISTICALINV:`(:ORY RECONCILIATION(SIR)• ❑ a. TANKTESTING <br /> BIENNIALTANKTESTING ❑99. OTHER - I <br /> V.TANK CLOSURE INFORMATION I PEFLMANENT CLOSURE IN PLACE <br /> I <br /> ESTIMATED PATE LAST USED(�9/MGCAY) ESTIMATED OWNTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MAT ERIAL7 <br /> anons ❑Yes <br /> y ❑No <br /> f <br /> Fct 1efjy SWRCS Fom1 J <br /> CUQAFORM(41991 <br />