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#e3 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 f„„,page$pe, a <br />Pa9a el <br />❑ S. CHANGE OF INFORMATION) 0 B. TEMPORARY SITE CLOSURE <br />TYPEOFACTION 01. NEW SITE PERMIT 0 L AMENDED PERMIT 0 T, PERMANENTLY CLOSED ON SITE <br />(Chock We it.. nilly) S N» a•brbeal »saNY) 0 a. TANK REMOVED 43O <br />0 3. RENEWAL PERMIT (Specy nuan f Pec Y 9 ., <br />FACILITY IV 0 R< <br />w' <br />CIA <br />BUSIzz <br />s» FACILITY NA �ar O J'n u'm"' All <br />LOCTHIN SITE OFBunap /(! <br />� 91 <br />C - L Qoa <br />I. TANK DESCRIPTION <br />TANK MANUFACTURER COMPARTMENTALIZED TANK 13 Y.. ❑ Na <br />TSPNKIDa <br />12 11 <br />fin �j/)__l� T/n�C 119as'. complete pna pa9a knaN mmpar:T.ene <br />�d7-V <br />I <br />/s_v <br />TANKUSE <br />432 � / •""---- <br />REGULAR UNLEADED <br />MOTOR VEHICLE FUEL <br />(IQ 1a <br />(IImaM1M. <pmplelr Pe'rWunl TYpe) <br />❑te. P0.EMIUMUNLEADEO <br />0 1. NOWFUELPETROLEUM <br />0,p MIOGRADEUNLEADED <br />0 3. CHEMICAL PROOUCT <br />COMMON NAME (hum Han , <br />/ <br />0 4. H,,A,MUS WASTE (IMludas �� <br />Used 04 <br />❑ ] FIBERGLASSIPLASTIC <br />Cn•nN/ <br />TYPE OF TANK <br />01, SINGLE WALL <br />(CAKk We kem -NY) <br />.01. DOUBLE WALL <br />TANK MATERIAL• pNnary Mc" BARE STEEL <br />(GeG aria kam ONy) 1. STAINLESS STEEL <br />TANK MATERIAL • aacmaary unk 0 1. BARE STEEL <br />(Check one Rem OMW 0 Z. STAINLESS STEEL <br />INTERIOR LINING <br />OR C <br />OR COATING <br />PROTECTION IF APPLI <br />(Ch.k pna ROM aNn <br />SPILL ANOOVERFILL <br />("ck N that apply) <br />❑ 1. RUBBER LINED <br />0 1. ALKYOUNING <br />1, MANUFACTUREOCATHOOIC <br />PROTECTION <br />❑ 1. SACRIFICIALANOOE <br />0 <br />0 5. JET NEL <br />1. LEADED <br />❑ 8. AVIATION FUEL <br />❑ 1 DIESEL <br />0 99. OTHER <br />❑ 4. GASOHOL <br />CAS a (hvm Ha»recus Matenats Inwnbryp <br />E <br />8C) 6- G/- <br />[195. UNKNOWN <br />❑ ] FIBERGLASSIPLASTIC <br />0 <br />YEAR INSTALLED TYPE(FCr <br />❑ 1. ALARM [13. FILL TUBE SNOT OFF VALVE � <br />0 1. SPILLCONTAINMENT ��- 0 S. LARALL FLOAT �_ 0 4. EXEMPT <br />02. DROPTUSE <br />�- <br />03. STRIKER PLATE "'•'^ <br />N. -TANK LEAK DETECTION --' <br />IF DOUBLE WALL TANK OR TANK WITHBLADOER (black ans'1 pNy1� <br />IF SINGLE WALL TANK aB <br />[3S. SINGLE WALL VATH INTERNAL BLADDER SYSTEM <br />❑ 3.SINGLE WALL WITH <br />. <br />EXTERIOR MEMBRANE LINER <br />095. UNKNOWN <br />0 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br />❑ 4, SINGLE WALL IN A VAULT <br />099. OTHER <br />0 B. <br />E <br />.3. C,NUALMOSINTERSTITIALMONITORING <br />0 ]. MANUAL MONITORING <br />[195. UNKNOWN <br />❑ ] FIBERGLASSIPLASTIC <br />0 5. CONCRETE <br />0B FRP COMPATIBLE WII00!L METHANOL <br />❑ 99. OTHER <br />STEEL CLAD WIFIBERGU5S <br />0 3. <br />CONTINUOUSATG <br />REINFORCED PLASNC (FRP)95. <br />0 S. FRP COMPATIBLE YJl1D0Y METHANOL <br />0 3 FISERGLASSIPLASTIC <br />ODIBLE JACKET <br />099. 0TmE0.� <br />04, <br />REINFORCED PLASTIC IFRi) <br />0 0. COATED S EE <br />❑ 5. CONCRETE <br />DATE INSTALLED <br />V. TANK CLOSURE INFORMATION I PERMANENT <br />± S�OTANK FILLED WITH INERT MATERIALT <br />0 S. GLASS LINING 095. UNKNOWN433 <br />ESTIMATED OVANTITY OF SUBSTANCE REMAINING <br />03, EPDXY LINING <br />❑ B. UNLINED 099. OTHER <br />(FOrbcil use pnP) <br />❑ A. PHENOLIC LINING <br />ganpna <br />OATEINSTALLEO <br />S 4x <br />44 FIBERGLASS REINFORCED PLASTIC <br />rW <br />099 OTHERS <br />)Far <br />❑ 4. IMPRESSED CURRENT <br />ipcal use Only) <br />OVERFILL PROTECTION EQUIPMENT. YEAR INSTALLED <br />YEAR INSTALLED TYPE(FCr <br />❑ 1. ALARM [13. FILL TUBE SNOT OFF VALVE � <br />0 1. SPILLCONTAINMENT ��- 0 S. LARALL FLOAT �_ 0 4. EXEMPT <br />02. DROPTUSE <br />�- <br />03. STRIKER PLATE "'•'^ <br />N. -TANK LEAK DETECTION --' <br />IF DOUBLE WALL TANK OR TANK WITHBLADOER (black ans'1 pNy1� <br />IF SINGLE WALL TANK aB <br />FO"edy SV4RCB F <br />mat ep k <br />0 S. <br />MANUAL GAUGING (MTG) <br />0 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br />0 1, <br />VISUAL (EXPOSED PORTION ONLY) <br />0 B. <br />E <br />.3. C,NUALMOSINTERSTITIALMONITORING <br />0 ]. MANUAL MONITORING <br />❑ 2. <br />AUTOMATIC TANX GAWING (ATG) <br />❑ T <br />GROUNDWATER <br />GROUNDWATER <br />' <br />0 3. <br />CONTINUOUSATG <br />❑B. <br />TANK TESTING <br />04, <br />STATISTICALINV`-.•RORYRECONGILIATON(SIR)• <br />Oqq <br />OTHER <br />BIENNIAL TANK TESTING <br />OLOSURE 1 <br />V. TANK CLOSURE INFORMATION I PERMANENT <br />± S�OTANK FILLED WITH INERT MATERIALT <br />DATE LAST USED(YRIMO �/ <br />ESTIMATED OVANTITY OF SUBSTANCE REMAINING <br />❑ ye.ONO <br />ESTIMATED <br />`K, <br />ganpna <br />FO"edy SV4RCB F <br />