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UNIFIED PROGRAM CONSOLIDATED FORM0)oz <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> II fD,.•o Faq's F^-r lank) I <br /> L ,!y,yoc,_ <br /> 1_v c r YU c, -.c' 7 Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ S.TEMPORARY SITE CLOSURE <br /> (Check ane itrm only) 13T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Sm,{J Aaam•lorfoeal usr au'J) (Spec+r'/change•lorlxal us*only) ❑ e.TANK REMOVED 4:0 --- --- --- <br /> FACILITY i <br /> BUSINESS NAME(Same as FA/GtUTY�NAME�or OBA•Doing Business As) 10 a T- ;• _3A <br /> LOCATION VATHIN SITE 431 <br /> -7j•K Z� vat= / <br /> L TANK DESCRIPTION <br /> TANK!INSTALLEO <br /> _ , TANK MANUFACTURER ^ COMPARTMENTALIZED TANK as ❑ No <br /> // Il-Yei•complete one page!Cr each ampa tMent <br /> YIN GA IONS NUMBEROFCOMPARTMENTSDATE (YEAR _ / <br /> 6 <br /> AOOITIONAL DESCRIPTtCN(Fes local use arty) <br /> II.TANK CONTENTS <br /> TANK USE 412 PETROLEUM TYPE <br /> , MOTOR VEHICLE FUEL ❑to REGULAR UNLEADED <br /> ❑ 2. LEADED ❑ 5. JET FUEL <br /> (I/madrQ complete PryrJew'1 Type) ❑1b. IUM UNLEADED ❑ 3. DIESEL ❑ 6.AVIATION FUEL <br /> ❑ 2.NON•FUELPETRCIEUM ❑ 4. GASOHOL ❑99. OTHER <br /> 1. miDGRAOEUNLEADEO <br /> ❑ 3.CHEMICAL PROCUCT COMMON NAME(ho nim Hasaaus Matenals Inr•ntory pays) GS a(from Hasan:ous Mataialr M�entory page) <br /> ❑ 4.HAZARDOUS WASTE(Includes <br /> Used 04) <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 7 3wGLE WAIL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLACCER SYSTEM <br /> C,3 EXTERIOR MEMBRANE LINER ❑95. UNKNOVlN <br /> (Chock one item only) 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL•prnary L21- ❑ 1. BARE STEEL 3. FIBERGLASS/PLASTIC <br /> ❑ S. CONCRETE [3 95 UNKNCV•N <br /> (Check one item only) ❑ 2. STAINLESS STEEL [34 STEEL CIAO WIFIBERGLASS C36. FRP COMPATIBLE W/100%AIET}LANOL ❑99 OTHE-Q <br /> -7- <br /> FORCED PLASTC(FRP) <br /> TANK MATERIAL-secondary Ona ❑ 1. BARE STEL c 3 FIBERGLASS I PLASTIC ❑ 6. FRP COMPATIBLE W1100%METHANOL C195.UNKNOWN <br /> 13 99 OTHER <br /> (Check one item only) [32. STAINLESS STEEL [3S 4 STEEL CLAD WIFIBERGLAS ❑ 9. FRP NON•CORROCISLE JACKET <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> •"❑ S CONCRETE <br /> �OATEi;NSTALLSDTANK INTERIOR LINING ❑ t. RUBBERUNED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNCVI»433 <br /> ORCOATNG ❑ 6. UNLINED ❑99. OTHER weCrfr) <br /> ❑ 2. ALKYO LINING ❑ 4. PHENOLIC LINING <br /> (Check one item WN) DATE INSTALLED <br /> OTHER CORROSION 43a _ <br /> PROTECTION If APPLICABLE ❑ t•M.ANUFACTUR EO CATHODIC ❑ 7. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN - <br /> PRCTECTION ❑ 4. IMPRESSED CURRENT Q 9^. OTNER (oarfoc <br /> (Check one dem art.) ❑ 2 SACRIFICIAL ANODE OVERFILL PROTECTION ECUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILLINSTALLED TYPE(For local use OW <br /> (Check as Mat appy) 1 cnrLL CONTAINMENT ❑ 1•ALARM ❑ 3. FILL TUBE SHUT OFF VALVE - <br /> 2P TUBE ❑ 2 S ALL FLOAT [34. EXEMPT <br /> 3. STRIKER PLATE - -- <br /> N.TANK LEAK DETECTION - <br /> W DOUBLE WALL TANK OR TANK WITH BLADDER(Checlt one dem only): <br /> IF SINGLE WALL TANK(Check all Nat aoaNt' <br /> ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 1- VISUAL(EXPOSED PORTION ONLY) ❑ 2 CONTINUOUS INTERSTITIAL MONITORING - <br /> ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6. YADOSE ZONE <br /> C] INL' <br /> 3. CCNTOUS ATG ' <br /> ❑ T, GRCUNO•NATER ❑ 3. MANUALMONRCRING <br /> ❑ 4, STATISTICAL INVst(TORY RECCNCIUATICN(SIR)• ❑ 6. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION)PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMGOAY) ESi17.UTED OWNTITY OF SUBSTANCE REMAINING <br /> 435 TANK flLLED WITH INERT MATo41AL? <br /> g a9ona ❑Yes ❑� <br /> Fotmerty VNRCS FoIR <br /> CLIPAFORM(4199) - <br />