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y . <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> OWO pa,-93 per rank) i <br /> I <br /> Page i of _-2- <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT 1.06, CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> (Check and dem only) <br /> / 117. PERMANENTLY CLOSED ON SITE <br /> 3.RENEWAL PERMIT {Specify reason-tor local use only) (Speuly change-for local use only) <br /> ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME((Sameass FACILITY <br /> YN / <br /> NAME or OBA-Do�inggBB%issiiness As) FACILITY ID# <br /> OL-111,00C <br /> 1 <br /> s H�i ddc <br /> LOCATION WITHIN SITE(0ptionaq 431 <br /> e,.�-�y <br /> f vc K-roi-J r--A QS 2c� <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTUREr7 <br /> n COMPARTMENTALIZED TANK ❑ Yes <br /> �L,•/f �, <br /> If'Yes',complete one page for eavi coAp ac-e-. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL A. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> {ff marked,complete PeP.raleum Type) ❑10 PREMIUM UNLEADED - ❑ 3. DIESEL ❑ e. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIOGRADE UNLEADED ❑ 4. GASOHOL 1-199 OTHER <br /> ❑ 3 CHEMICAL PRODUCT <br /> COMMON NAME(Rom Hazardous Materials Jnvsnlcry page) CAS#(from Hasa+dous Maleriafx Inventory page) <br /> ❑ 4. HAZARDOUS WA57E(Includes , <br /> Used DrgvMP� <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑l SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Cheri one item only) LSf 2.. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-pnmary tank ❑ 1 BARE STEEL 3. FIBERGLASS f PLASTIC ❑ 5. CONCRETE ❑95 UNKNOWN <br /> (Check ane dem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE W1100%METHANOL ❑99, OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secanoary tank ❑ 1 BARE STEEL 3. FIBERGLASS I PLASTIC ❑ A. FRP COMPATIBLE W1100%METHANOL ❑95 UNKNOWN <br /> (Check one item only} ❑ 2, STAINLESS STEEL ❑ 4,. STEEL CLAD WTZBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 1199 OTHER <br /> REINFORCED PLASTIC(FRP) 1110, COATEO STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LtNRIG ❑ 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOIAN433 DATE INSTALLEC <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING V B UNLINED ❑99. OTHER <br /> (Check ane rfem only) (Far local use 0,1 1 <br /> OTHER CORROSIONEl 1. MANUFACTURED CATHODIC 53� FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 434 DATE INSTALLS] <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4, IMPRESSED CURRENT C3 99 OTHER <br /> (Check ons ilem only) ❑ 2. SACRIFICIAL ANODE {Forlxal use anrjJ <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal us"only} OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ax that apply) <br /> �l1. SPILL CONTAINMENT ,..,J1.ALARM ( S 3, FILL TUBE SHUT OFF VALVE <br /> L�W,,/2. DROP TUBE f f.1d'2. BALL FLOAT ) =�❑ 4" EXEMPT <br /> LY( 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all lhaf ap ). IF DOUBLE WALL.TANK OR TANK WITH BLADDER(Check ons Adm onlyl <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 11. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) C38. VADOSE ZONE V2. CONTINUOUS INTERSTITIAL MONITORING ^ <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> Q 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ H. TANK TESTING <br /> 819NNIAL 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 /> gallons ❑Yes ❑No <br /> CUPAFORM(4799) <br /> Formerly SWRC9 Farm B <br />