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USD PROGRAM CONSOLIDATED FORNO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page= TYPE OF ACTION 1.NEW PERMIT 114.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION [I 6.TEMPORARY TANK CLOSURE 430. (acck one item anty) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Saifyma oo) (spociry-amr) ❑ 8.TANK REMOVED BUSINESS NAME(Same n FACILITY NAME or DBA-Doing Beninese As) 3. FACILITY ID: 1, fA'1T e4'Ve Ct/ 44- VAk.L'�( LLe- D 7 tDA7TE TION WITHIN SITE(Optiona0 431. I.TANKDESCRIPTION (Ascaled lot plan with the location of the UST system includingbuildingsand landmarks shall be submitted to the local agency.) TA 432.�STI<a TANK MANUFACTURER 433. (� COMPARTMENTALIZED TANK Yes No 434. INSTALLED 435. TANK CAPACITY IN GALLONS U6. NUMBER OF COMPARTMENTSR/MO) 437. (.trc�J 20,OOC7 ADDITIONAL DES RIP I ION(Far kcal...1y) 43e. H.TANK CONTENTS TANK USE 439. PETROLEUM TYPE X1. MOTOR VEHICLE FUEL ❑IL REGULAR UNLEADED [37 LEADED ❑S. JET FUEL aaa (Ifehmkcd,corrglom Petmlcum Type) PREMIUM UNLEADED DIESEL❑ 2. NON-FUEL PETROLEUM ❑6. AVIATION GAS ❑Ic. MIDGRADE UNLEADED [:]4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ham Hamrrdoen moows Inventory page) µl' CAS#(from Huardom Mmciab lnmtory page) U2, ❑ 4. HAZARDOUS WASTE (InclW.Ussd oi0 ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK U 1. SINGLE WALL J. SINGLE WALL WITH EXTERIOR 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOABLE WALL . SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary uvk 1. BARE STEEL . FIBERGLASS/PLASTIC ❑5. CONCRETE 0 95.UNKNOWN 414. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑e. FRP COMPATIBLE ❑99.OTHER: REINFORCEDA3,. W/100% TANK MATERIAL-seory1. BARESTEEL J. FIBERGLAS FRP COMPTIBLE W1100%METHANOL 0 95.UNKNOWN 4a5. (Check ane item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING Q 1.RUBBER LINED L1 3.EPDXY LINING 0 5.GLASS LINING 95.UNKNOWN aas. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED 99.OTHER Check one item only) /SOC J OTHER CORROSION---CFI MANUFACTURED CATHODIC 01 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN a4g. DATE INSTALLED a9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER if Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION E UIPMENT: YEAR INSTALLED ra-iasx. (Check all that apply) 1.SPILL CONTAINMENT (Zc10,': Z4, �LALARM V•aocT 993.FILL TUBE SHUT OFF VALVE2.DROP OP t 3.STRIKER PLATE -1/'Lx':: c+?141 2.BALL FLOAT_ ❑4.EXEMPT - i IV.TANK LEAK DETECTION (A description of the monitoring program shall he submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑L VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ASG) ❑6.VADOSE ZONE2.CONTINUOUS INTERSTITIAL MONITORING ❑1.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457. gallon ❑Yes ❑ No UPCF hwfwrc-b(1/99).1/4 h"p:/Iw".unidoes.org Rev.02116100