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a U NIF I ED P RO G RA M C ONS O LIDATED FOR M =1�2'__OIANKS) <br /> UNDERGROUND STORAGE TANKS -TANK PA <br /> Papa _ oI _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (CA>Q Dna ilom amyl ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SPK�•namn JPNOGalun ernY) (SpeNlyWrge-brlaal uv only) ❑ S. TANKREMOVED 430 <br /> BUSINESS NAMEI$amuaFACILITY NAME or DBA-Co'nq Bminaa Aa) FACWTY IV (yL )�/1aoofi�8' <br /> OCJf <br /> LOCATION WITHIN SITE(GPM' 431 <br /> U <br /> J /'1 <br /> 1.TANK DESCRIPTION <br /> TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No <br /> Q� It Yai TgAnpbla one <br /> TANK 10• Dage foruNTa¢La tnanl. <br /> aT NUMBERCFCOMPARTMENTS <br /> DATEINSTALLE JIYEARJMOI ��� TANK WPACITY INW�$ / <br /> Oa`CaJ- �' D CJ O O a <br /> ADDITIONAL DESCRIPTION(Forlocal ws any) ) O {•` <br /> ' ^,A4x <br /> ILTATNK CONTENTS <br /> �� TANK USE 432 lO PETROLEUM TYPE ❑ 5 JET FUEL <br /> Wt MOTOR VEHICLE FUEL la REGULAR UNLEADED <br /> F[32 <br /> DED(llm>heO,GpmpMle PelMeprtl Typel 10. PREMIUM UNLEADEDSEL 8. AVIATION NEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc. MIOGRADE UNLEADED SOHOL ❑99. OTHER <br /> ❑ 3 CHEMIWLPROOUCT COMMON NAME(/ mHaxaAam M>hllala/l nforypagsJ GASa(Imm Hala/Epu4 Mahnal/a l^nwnmry P>9e) <br /> NAZA <br /> ❑ 4 U 4x01) US <br /> WASTE(IrcJWea /�v� O 6 �, <br /> `f V' AIL TANK CONSTRUCTION <br /> TYPE OF TANK 1 NGLE WALL ❑ ]. SINGLE WALL WITH ❑ S. SINGLE WALL W1TX INTERNAL BUDDER SYSTEM <br /> EXTERIOR MEMBRANE LINER 0 95. UNKNOWN <br /> (Cnacx Pnubm poly) . DOUBLE WALL 4. SINGLE WALL IN A VAULT <br /> [199, OTH R <br /> TANK MATERIAL-pxmary lank ❑ ]. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOW): <br /> ❑,..,,�1. BARE STEEL <br /> (Cnxk ane nem Dory) k2. STAINLESS STEEL ❑4. STEEL CUD WIFIBERGLASS ❑ B FRP COMPATIBLE W/100%METlIANOL Cl 99. OTHER <br /> REINFORCED PLASTIC IFRP) <br /> TANK MATERIAL-aecmEary Lank 0 J. BARE STEEL ❑ 3. FI ERGLASS/PLASTIC ❑ 5. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check pns item oMy) ❑ 2. STAINLESS STEEL . STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON CC <br /> JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) [310 COATED STEEL <br /> ❑ S.CONCRETE <br /> OAT EJMS' <br /> ALL <br /> E ,Y <br /> TANK INTERIOR LINING 1 RUBBER LINED ❑ ]. EPDXY LINING ❑ 5. GLASS LINING ErI,5. UNKNOWN4]] <br /> OR COATING (� <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED ❑99. OTHER (FPrloca/ sonl <br /> (CALF ane item pnl) DATE INSTALLED .7 <br /> OTHER CORROSION1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINfORCEO FUSTIC I 95. UNKNOWN 434 <br /> PROTECTION IF APPUOABLE PROTECTION ( pr Mme aNy) <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (CAecx one AIA,oAyl ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(for loctl we Dory) <br /> (CAcka4lANPpy1 SPILL CONTAINMENT 1.ALARM _� ] FILL TUBE SHUT OFF VALVE <br /> Z. DROP TUBE <br /> ❑ 2. BALL FLOAT_ ❑ 4. EXEMPT <br /> YL]. STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER'CAck oro aem ONY) <br /> IF SINGLE WALL TANK C04ck 0MaN <br /> ❑ 5. MANUAL TANK GAUGING(MTC) ❑ 1. VISUAL(SINGLE WALUMVAVLT ONLY) <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) <br /> ZCONTINUOUS MONITORING <br /> El 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSE ZONE . <br /> ❑ 3. CONTINUOOSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/WY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 9a4om Y ❑N <br /> Fo(mBM SWRCS Forth <br /> CUPAFORM(4199) , <br />