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Ila TIED PROGRAM CONSOLIDATED FO II IU D1 \ NYS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two page per tank) ergf of_ TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT K 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one iMn only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spccifyrcason-fmlouluuonly) (Specifyinnoon-forloceluaeonly) ❑ S TANK REMOVED 430 BUSINESS NAME(S.u FACILITY NAME or DBA-Doing Booms.All FACYY ID: I 1 LOCATION THIN SI (Dptinnv) ts3� (A-.is&' yf- 431 L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# l I 431 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK [IYes o 434 4';e-- ^-f�r/& S O(,[.)ew's 4 u"Ya".complh one page for wch comparnnent. DATE INSTILLED(YEAR/MO) 435 TANK CAPACITY IN GALLO a36 NUMBER OF COMPARTMENTS 437 ss a ✓/ DOa ! s *d ADDITIONAL DESCRIPTION(Fm meal we only) 439 II.TANK CONTENTS TANK USE d39 PETROLEUM TYPE 4410 C I. MOTOR VEHICLE FUEL Al.. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Inn eked eomple¢Pe roleum Type) ❑Ill. PREMIUM UNLEADED [13. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Haesrdous Materiels Inventory page) 441 CAS#(from Hvardow Materials Inventory page) 402 ❑4. HAZARDOUS WASTE (Inclo&nthen!On) Ukr../ Vol AeJa &J 9&-50%.9e 4s l- 9 [195.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 0 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check arat wincely) EXTERIOR MEMBRANE LINER [3 95. UNKNOWN %2. DOUBLE WALL [14. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary lanls 0 1. BARE STEEL jq 3. FIBERGLASS/PLASTIC U 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-sxondary lank 0 1. BARE STEEL X3. FIBERGLASS/PLASTIC LIS. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING Ll L RUBBER LINED 0 3.EPDXY LINING JW5.GLASS LINING 95.UNKNOWN 4416 DATE INSTALLED rot OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check oro item only) (Fm lout use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC X3 FIBERGLASS REINFORCED PLASTIC [395 UNKNOWN 448 DATE INSTAL �Z 9 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER �Y (Check oro item only) ❑2 SACRIFICIAL ANODE (For Iacal use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE dol use Duly) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 453 (Check an that apply) X I SPILL CONTAINMENT 0 ALARM 693 FILL TUBE SHUT OFF VALVE 09 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT Iffi 3 STRIKER PLATE IV.TANK LEAK DETECTION(A de cro inn oftl,e monitoring pno®am.hall be submitted to the locel.ge y.) IF SINGLE WALL TANK(Chwktll that apply) 653 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑l VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATC) ❑6 VADOSE ZONE 9(2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑S TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOMAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 4V gallons []Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B