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fly- o IQO\06\�'} <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> I UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (rh Ga.'s per tar.j I <br /> dc� os r <br /> Yom+-,-1 -7Page <br /> - - <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT [3S.CHANGE OF INFORMATION) Cl 6. TEMPORARY SITE CLOSURE <br /> ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Check ane item only! _ <br /> ❑]RENEWAL PERMIT (5 ;{J n.aaon•tar total use onri) (Spec,11cA•n4e•fvrlxal use Dory) Cl 8. TANKREMOVED 4:A <br /> FACtUT f IO I 1 <br /> BUSINESS NAME(Same as FACILITY NAME or IDEA•OaIr.9 8usu+oss As) <br /> FFU <br /> N000 <br /> LOCA, NY,THIN SITE(0;::1149 -1 <br /> I.TANK DESCRIPTION <br /> TANKMANUFACTURER COMPARTMENTALIZED TANK En Yu ❑ No <br /> TANK 10 0 It Yes••com;Iate one Paso w fact=MpartaenL <br /> NUMBER CF CCMPARTMENTS <br /> DATE INSTALLED(YEAFLVO) <br /> TANK CAPACITY IN GALLONS <br /> ADDITIONAL OESCAtPT1CN(Farfocal use Dory) - <br /> 11.TANK CONTENTS <br /> TANKUSE 472 PETROLEUM TYPE ❑ S JET FUEL <br /> ❑1a UWtUNLEADED ❑ 2. LEADED <br /> 1.MOTOR VEHICLE FUEL ❑ 6. AVIATION FUEL - <br /> (If ,4 Complelo Po:rcAo"Type) 1p pREMIUM UNLEADED ❑ 4. DIESEL <br /> ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 2. NON-FUEL PETRCLEUM C]1, MICGRADE UNLEADED I <br /> ❑ 2.CHEMICAL PRCCUCT 'y page) <br /> CAS a(tram HazuCous Ma:enals lnvenfor/pa;e) <br /> COMMON NAME(from Halardaus Mafenala Imnnta <br /> Cl 4. HAZARDOUS WASTE(lr Jwdos <br /> Used 04) <br /> r <br /> - 111.TANK CONSTRUCTION <br /> TYPE Of TANK ❑ 1. SINGLE WALL ❑ ]. SINGLE R LLYATHMEMBRA <br /> ❑ S. SINGLE WALL Y.1TH INTERNAL BLAOOER SYSTEM <br /> }��/ EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one Rom only) l COUBLE WALLC3� 4, SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-pnmarl tar• ❑ 1 BARE STEEL 7. FIBERGLASS/PLASTIC <br /> ❑ S. CONCRETE ❑95 UNKI9O'..`l <br /> (C++eck one item anyJ ❑ 2. STAINLESS STEEL ❑4 STEEL CLAD WIfIBERGlJ.55 ❑ e. FRP COMPATIBLE WI1C0!'.METHANOL [3 S9 OTHER <br /> NFCRCED PLASTIC(FRP) <br /> 7 FIBERGLASS I PLASTIC ❑ e. FRP COMPATIBLE W110C%METHANCL ❑95.UNKNC-AN <br /> TANK MATERIAL•seceneary lana <br /> Cl1. BARE STEEL ❑99. OTH.EA <br /> (Check ono item only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CUD WIFIBERGLASS� [:19. FRP NCN-CORRCCIBLE JACXET <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> .•❑ S CONCRETE OATS INSTALLED <br /> TANK INTERIOR LINING Cl 3. EPDXY LINING ❑ S. GLASS LINING ❑95. YM477 <br /> OR COATING ❑ 1. RUBBER LINED <br /> [14 PHENOLIC LINING ❑ e. UNLINED Cl 99. OTHER OOTHER (Far bca/uae an!•rl <br /> ❑ 2. ALKYD LINING DATE INSTALLED <br /> (Check am Aem onty) 474 <br /> OTHER CQRRO51CN ❑ 1 MANUFACTUREO CATHODIC ❑ S. FIBE4GLASS REINFORCED PLASTIC ❑45. UNKNOWN <br /> PROTECTION IF APPUCA3'-9 PRCTE"TICN ❑99.OTHER rr.r;«a. <br /> .. ❑ 4. IMPRESSED CURRENT <br /> (Chock one item COW Cl 2. SACRIFICIAL A.4COE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For focal use 0-Y) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED - <br /> (cj?•ck as feat appy) ' ILL CONTAINMENT ❑ 1.ALARM ❑ 0. FILL TUBE SHUT CFF VALVE <br /> RCP TUB= ❑ 2 BALL FLOAT ❑ 4. EXEMPT <br /> 1 STRIKER PLATE <br /> TV.TANK LEAK DETECTION <br /> IF nCUBLE WALL TANK OR TANK WITH BLACCER(G`eCk one item Crlq: <br /> IF SINGLE WALL TANK(G4ect all Nat 800A•1' <br /> ❑ S. MANUAL TANX GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) - <br /> Cl 1, VISUAL(EXPOSED PORTION ONLY) ❑ 2. CONT)NUCUS INTERSTTtAL MCNITCRING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) Cl e. VADOSE ZONE <br /> ❑ 3. CCNTINCOUSATG <br /> E] 7. GRCUNC-NATER ❑ ]. MANUAL MONRCRING <br /> Cl 4. STATISTICAL INVSYTCRY RECCNCIUATICN(SIR)• ❑ e. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. 0--- <br /> V.TANK CLOSURE INFORMATION I PER.-AANE.4T CLOSURE IN PLAC7 <br /> ESTIMATED CA--LAST 0520(YRAACiCAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 475 I TANK FILLED WITH INERT MATERIAL? <br /> yaJons ❑Yes ❑No <br /> =_rmefy <br /> CUPAFORM(4.59) <br />