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IED PROGRAM CONSOLIDATED FO• 6l <br /> ANK(� <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 `rte <br /> (Asv pagesy r <br /> Pape _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT EA S. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> (Check one Nem o*) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑].RENEWAL PERMIT (Spacilynalan-lorloolu»only) (SpocyOnanga-briwal use only) 13 B. TANK REMOVED 430 <br /> OUSINE55 NAME(Same as FACILITY NAME or OSA-Opirq Buaina»Aa) FACILITY 100 - 1 <br /> 'ur <br /> LOCATION THIN SITE( p snag 4]1 <br /> I.TANK DESCRIPTION <br /> TANKIDO 1 O D1 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yo No <br /> If Yes',mmplate pna Page fpr BaclI..pamnenl. <br /> Tank 011 Fluid ContainnIgnt <br /> DATE INSTALLED(YEAR(MO) TANKCAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 03 <br /> ADDITIONAL DESCRIPTION(Fa local u»aMy) <br /> 11.TANK CONTENTS <br /> TANK USE 4I2 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL C1 L. REGULAR UNLEADED TO . LEADED ❑ 5. JET FUEL <br /> of.Aad.."'Ph".Pefm um Typal ❑1E. PREMIUM UNLEAOED DIESEL e. AVIATIONFUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIOGRADEUNLEADED . GASOHOL ❑N. OTHER <br /> ❑ ].CHEMICAL PRODUCT COMMON NAME(9om H]nAaO Mabdala lrrnnmrypapa) CAS If(Imm Hazanfous MaNdals In anhry Pays) <br /> ❑ a. HAZARDOUS WASTE(IrclWea <br /> Ned Dig <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ ]. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check pnufem only) l?2. DOUBLE WALL ❑ A SINGLE WALL IN A VAULT <br /> ❑ <br /> moi. 99. OTHER <br /> L <br /> TANK MATERIApMnary Mnk ❑ 1 BARE STEEL EX3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 13 95 UNKNOWN <br /> (Check One dine"1Y) ❑ 2. STAINLESS STEEL 04_ STEEL CLAD WIFISERGLASS ❑ 8. FRP COMPATIBLE WI100%METHANOL 1199. OTHER <br /> O1 REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL secondary Nnk ❑ 1. BARE STEEL .y+ 1 FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WII00%METHANOL 095. UNKNOWN <br /> (Cheri am d0m pny) ❑ 1 STAINLESS STEEL ❑ a.ISTEELCLAD IFIBERGFRPS 119. FRP NON-0ORROOIBLE JACKET 099. OTHER <br /> ❑10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR UNINGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ ]. EPDXY LINING ❑ 5. GU55 LINING 095. UNKNONMa]] <br /> ❑ 2. ALKYO LINING C1 a. PHENOLIC LINING ❑ B UNLINED ❑99. OTHER (forbcal vee on ) <br /> (Cmckwelfemo ) _T___DATE INSTALLED <br /> OTHER CORROSION ❑ 1, MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REINFORCED PLASTIC 095. UNKNOYM 4U <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ a. IMPRESSED CURRENT 099.OTHER (Fprbcal uas pny) <br /> (LhepkOM Nam prvy) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlpcal use nnW OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CheckaxfmfaPpM ❑ 1. SMLLCONTAINMENT ❑ 1. ALARM _ ❑ ]. FILL TUBE SHUT OFF VALVE <br /> ❑ Z. DROP TUBE ❑ 2. SALL FLOAT_ ❑ K. EXEMPT <br /> ❑ ]. STRIKER PLATE <br /> IF SINGLE WALL TANNAack atl fmla ): IF DOUBLE WALL TANK OR TANK WITH BUDDERCnack om inm on : <br /> ❑ L VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) y❑., 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING INTO) ❑ B. VADOSEZONE 4sJ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ ]. CONTINUOUSATG ❑ T. GROUNDWATER ❑ ]. MANUALMONITORING <br /> ❑ a. 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(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gawns ❑Yes ❑No <br /> CUPAFORM(4199) For SWRCI3 Form B <br />