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U N IF I EDP ROGRAM C ONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1pages per tank) <br /> Page _ Of - <br /> W.CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT [14.AMENDED PERMIT ❑ T. PERMANENTLY CLOSED ON SITE <br /> (Cheek Ona item Onty) �� B elrange-brleeal uss aHyl ❑ S.TANKREMOVED 430 <br /> ❑].RENEWAL PERMIT (9peeiyleavon-br lomluseonty) (p°Oy 1 <br /> FACILITY IO F <br /> B�uS\INESS NAME(S+ms as FACILITY NAME Or DBA-DDIn9 Bu us A')�O�� G ' <br /> t - co <br /> LOCATION WITHIN SIT pBOna0 471 <br /> 1.TANK DESCRIPTION Yes <br /> COMPARTMENTALIZED TANK <br /> le a One Page fo❑ <br /> TANK MANUFACTURERr carr mmparPnent <br /> 1NKIDM V �� a-, �/Y <br /> 7lSJ 11 NUMBER OF COMPARTMENTS <br /> TANK CAPACITY IN GALLONS <br /> DATE INSTALLED(YEPRRaO) <br /> ADOITIO LD S RIPTION(FOrbeal 030 only) <br /> 11.TANK CONTENTS <br /> TANK USE 4]2 -�cp PETROLEUMTYPE ❑ IIIESEL <br /> D ❑ 5. JET FUEL <br /> r. REGUURUNLEADEO ❑ 6. AVIATION FUEL <br /> 1MOTOR VEHICLE FUEL99.OTHER <br /> Il maMeC,complete PaboNumTypal ❑1p PREMIUM UNLEADED ❑ HDL <br /> ❑ 2. NON-FUELPETROLEUM ❑tc. MIOGRADEUNLEAOEO <br /> CAS 4(hom Haxaltlom Mabrtab Imanfary p89e7 <br /> ❑ ]. CHEMICAL PRODUCT COMMON NAME Qom Haaallous Mafenala lnwnmrypage) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Uaad 014 <br /> III.TANK GON3TRUCTION <br /> ❑ ]. SINGLE WALL VdiH <br /> ❑ 5. SINGLE WALL WATN INTERNAL BLADDER SYSTEM <br /> TYPE OF TANK ❑ 1. SINGLEWALL EXTERIOR MEMBRANE LINER ❑95 UNKNOWN <br /> (Check One item onlyl A, DOUBLEWALL '❑ 4.SINGLE WALL IN A VAULT ❑99 OTHER <br /> 1. BARE STEEL ❑ ]. FISERGUSSIPUSTIC <br /> ❑ 5. CONCRETE ❑95. UNKNOWN <br /> TANK MATERIAL-P^maty tank <br /> 99. OTHER <br /> (Check Ons item any) -❑ 2. STAINLESS STEEL ❑4 STEEL REINFORCED PIUSTCIFRPS ❑ 5 FRP COMPATIBLE WI1001'e METHANOL <br /> 95 <br /> TANK MATERIAL-seeoneary unk 1 BARE STEEL <br /> ❑ ].REINFORCED PLASTIC( ❑ B. FRP COMPATISLE WI100%METHANOL ❑99. OTHER <br /> FISIER <br /> 09 FRP <br /> (Cheek One item Only) '.. STAINLESS STEEL ❑ 4- STEELRCEDPUSERGLASS ❑10. COATEDSTEEL <br /> NON-CORRODIBLE JACKET <br /> ❑ 5. CONCRETE GATE[3INSTALLED <br /> ❑ ]. EPO%V LINING 5 CUSS LINING ❑95. UNKNOWN4]] <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED 8 UNLINED 099. OTHER (FOrlocal ma Dory) <br /> (Cheek ibmon <br /> ORCOATING ra4. PHENOLIC LINING 13 " <br /> IATIINSTALLEIU <br /> Cl) <br /> Cl 2. ALKYDLINING <br /> OTHER CORROSION �. MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REIN FOftCEO PLASTIC ❑99. OTHE0 95 R 4 (FPrlocalmeOnly ) <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br /> (Cheek One item Doty) ❑ 2. SALRIFICIALANOCE TYPE(Forlxal use ONy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> YEAR INSTALLED <br /> SPILL AND OVERFILL RM ❑ ]. FILL TUBE SHUT OFF VALVE <br /> 1. AU <br /> (Chock as that apply) 1. SPILL CONTAINMENT - <br /> - ❑ 2. BALL FLOAT- ❑ 4. EXEMPT <br /> ❑ 2. DROPTUSE <br /> ❑ ]. STRIKER PUTE <br /> N.TANK LEAK DETECTION <br /> IF DOU9LE WALLTANK OR TANK WITH BUDDER(Check one item only): <br /> IFSINGLE WALLLTANK Chak)IWI OV8 ): ❑ 1. VISUAL(SINGLEWALLIN VAULT ONLY) <br /> ❑ S. MANUALTPNK GAUGING(MTC) l.N <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) .132. CONTINUOUS INTER3TITIAL MONITORING <br /> ❑ 8. GROUNVADOSDWATEZONER <br /> Cl ] MANUAL MONITORING <br /> Cl 2. AUTOMATIC TANK CAWING(ATG) ❑ T GROUNDWATER <br /> ❑ 3. CONTINUOUSATG ❑ 8. TANKTESTING <br /> ❑ 4. STATISTICALINVENTORYRECONCIUATION(SIR)• <br /> BIENNIAL TANK TESTING ❑99. OTHER-� <br /> V.TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE I<PLACE <br /> FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE UST USED(YRIMOIDAY) ESTIMATED QUANTITY Of SUBSTANCE REMAINING <br /> -�9albns ❑Yes ❑No p <br /> • <br /> cAlp;q <br /> CUPAFORM(4/99) <br />