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UNIFIED PROGRAM CONSOLIDATED FORM V SZ7� ANKS <br /> T <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 �lJ� <br /> ' (twp Pages Per tank) <br /> PaOa _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ L AMENDED PERMIT ❑ 5. CNANGEOFINFORMATION) ❑ 5. TEMPORARY SITE CLOSURE <br /> ([neck one ilem DNyl ❑ ?. PERMANENTLY CLOSED ON SITE <br /> ❑S.RENEWAL PERMIT (SP-dymason�/orlDPl uae aNy) (SFeay rJurpe-brloalun oNy) ❑ 5. TANK REMOVED 400 <br /> BUSINESS NAME(Same a FACILITY NPME or DBA.GoArg BAArua Aa) FACILITY 10 F 1 <br /> J v� 7�P,Qli6G L2 f n <br /> LOCATION_M SITE(OPOOnsf 401 N <br /> / I cel <br /> J <br /> I.TANK DESCRIPTION <br /> TANK I09 ry TAHKMANUFACTURER a COMPARTMENTALIZED TANK Yu ❑ No <br /> 0 <br /> ��17 ] T�/�� -r� IITai,camDlala Dna IM,lDr aagf TsmLY.n<nl. <br /> TANK[APA/CITTIN GALLONS w �j N NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEARIMO) O 3 <br /> �u GAeT 9d �� <br /> ADDITIONAL DESCRIPTION(Farlocal uaa aMy) �!J�/ A„ /��Q I __ � �Q <br /> 11.TANK CONTENTS <br /> ,a,// TANK USE 401 PETROLEUM TYPE ❑ 2LEADED ❑ 5 JET FUEL <br /> ll t MOTOR VEHICLE FUEL ❑1. REGULAR UNLEADED .,/. g AVIATION FUEL <br /> (Il maMeG.DDmpMH NDvIeum Type) 01D. PREMIUM UNLEADED g J. DIESEL <br /> ❑ 2. NOWFUELPETROLEUM E]tc MIDG0.AOE UNLEADED El 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICALPPOOUCT <br /> COMMON NAME gra.HaaBOYa MaMala GS 0(Imm <br /> HaaNDw MaNna <br /> ls lm�enb�ry <br /> ❑ 4HAZARDOUS WASTE(IGuEsa /w/� T(N' <br /> Ua0a0 D ^JKz4 <br /> Ill. Pr <br /> e) <br /> TANK CONSTRUCTION <br /> TYPE OF TANK 1 INGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> IOneck ons eem-MY) 2. DOUBLE WALL ❑ 4 SINGLE WALL IN A VAULT <br /> ❑99. OTM R <br /> TANK MATERIAL.pnmary tankec [13. FIBERGLASSIPLASTIO Cl 5. CONCRETE �9f. UNKNOWN <br /> ❑ 1, RESTEEL <br /> (CnM one Mm.*l2. STAINLESS STEEL ❑4 STEEL CILAD WNIBERGILASS [3 B FRP COMPATIBLE W1100%METHANOL ❑98. OTHER <br /> RE NFORC50 PLASTIC(FRP) <br /> TANK MATERIAL sem day Mnk r BARE STEEL ❑ 3. BERGLASS I PLASTIC ❑ B. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) STAINLESS STEEL 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON'COHRODIBLE JACKET Cl 99 OTHER <br /> REINFORCED PLASTIC(FRP) ❑W COATED STEEL <br /> ❑ 5. CONCRETE <br /> AL <br /> TANK INTERIOR LINING 1 ClRUBBER LINED ❑ 0. EPDXY LINING , S. GLASS LINING 95PATE INSTLED <br /> . UNMOM433 <br /> ORCOATING pZX�%T(l D <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ B UNLINED ❑99. OTHER (Forloca eon 1 <br /> (Check one ilemp ran/ DATE INSTALLED <br /> l <br /> OTHER CORROSION I. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWM 4NI a <br /> PROTECTION IF APPLICABLE PROTECTIONF O <br /> ❑ 4. IMPRESSED CURRENT [199. OTHER (For leat vae pNy) <br /> (C'r*am O.m ony) ❑ 2.SACRIFICIALANOOE <br /> SPILL AND OVERFILL fi YEAR INSTALLED TYPE(Forwal we ony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> ICMck a a fA.I.PPIv) 1. SPILL CONTAINMENT 1. ALARM - I52� E <br /> FILL TUBE SHUT OFF VALV <br /> Z,Y/DROP TUBE ❑ 2. BALL FLOAT__ Cl 4 EXEMPT <br /> ISS. STRIKER PLATE <br /> rV.TANK LEAK OETEC➢ON <br /> IF DOUBLE WALL TANK OR TANK WITH BLAOOER'Chwk one aem or ): <br /> IF SINGLE WALL TANK Che x AM Mac APPW <br /> ❑ 5. MANUAL TANK GAUGING(MTG) Cl 1. <br /> INTERSTITIAL MONITORING <br /> . VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) <br /> [32. AUTOMATIC TANK GAUGING(ATG) ❑ G. VAOOSE LONE I!7 z. <br /> ❑ 3. CONTINUOVSATG ❑ T. GROUNDWATER ❑ 0. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 3. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(VRRAOMAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> paoa ❑TIM 0 N <br /> Forrngrry SVJRCB Form <br /> CUPAFORM(4199) <br />