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' UNIFIED PROGRAM CONSOLIDATED F O RM <br /> T <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (hvo ages Per tank) <br /> ., <br /> P <br /> �/ apa <br /> - Ot <br /> YQ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT / ❑ T, PERMANENTLY CLOSED ON SITE <br /> (Ch�ckOM Ilam pMY) !� <br /> 03.RENEWAL PERMIT (Bpapny mason-krroul use aryl (Specny chappa-rorlodluse oNy) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Same sa FACIUtt NAME or DBA-Doing aineas As) <br /> FACILITY ION <br /> r <br /> hLION WITHIN SITE(OPUDW 'O <br /> I.TANK DESCRIPTION <br /> TANKIDM !L TANK MANUFACTURER COMPARTMENTALIZE7TANK ❑ Yea ❑ No <br /> �� D -T 1 IPYd,/ TANK CAPACITY IN GALLONS U <br /> DATE INSTALLED(YEARIMO) <br /> a - /? <br /> ADDITIONAL DESCRIPTION("-"e OnW <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑ 2. LEADED <br /> (nmehey cemplem Neva m type) 0 lb PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADEUNLEADED ❑ 4. GASOHOL 099. OTHER <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME CAB a(hom Hazar ous Melenals Inrenmry page) <br /> (ham Hexanfous Mammals Inrentorypage) <br /> ❑ 4, HAZARDOUS WASTE(Iridutles <br /> Used 09) <br /> IN.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALLVATH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (CM kone from only) ❑ 2. DOUBLE WALL � 4, SINGLE WALL IN A VAULT X0. OTHER <br /> TANK MATERIAL-pnmery lank 01 BARE STEEL <br /> ❑ 3. FIBERGLASS/PIASTIC ❑ S. CONCRETE 095. UNKNOWN <br /> (CM1eck aro nem Dory) ❑ 3. STAINLESS <br /> STEEL 0 4. STEEL CLAD WIFIBRGILASS <br /> ---- B. FRP COMPATIBLE WI100%METHANOL ❑99. OTHER <br /> REINFORCED PLAS <br /> TANK MATERIAL-s.neary tank 0 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Ohaomilem.Wy) ❑ 2. STAINLESS STEEL D 4 STEEL CLAD <br /> EDP/LASERGI-AS X 10. COATED NON-CORRODIBLE <br /> ON-C R ODIBLE JACKET ❑99. OTHER <br /> ck <br /> ❑ <br /> S. CONCRETE <br /> GATE INSTALLED <br /> TANK INTERIOR LINING 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASSUNING ❑95. UNKNOWN4]3 <br /> ORCOAnNG ❑ 4. PHENOLIC LINING ❑ S. UNLINED ❑99. OTHER <br /> ❑ 2. ALKYD UNING (Fwlacaluseonl) <br /> (Checkwmitamo ) DATE INSTALLED <br /> OTHER CORROSION 1. MANUFACTUREDCATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPUCABLE PROTECTION ❑99. OTHER (FOrlowluse only) <br /> ❑ 4. IMPRESSED CURRENT <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILLAND OVERFILL YEAR INSTALLED TYPE(FOrlooluse any) <br /> (Check ad Mal apply) 1 SPILLCONTAINMENT ❑ 1. ALARM �_ 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALLFLOAT_ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> '!IV..TANK LEAN DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER CM1eck ane imm Dory): <br /> IF SINGLE WALL TANK(Check all that appy): 1, MSUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTC) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSEZONE ❑ 3. CONUALMOSTORLN INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ L STATIBTICALINVEWORYRECONCIUATION(SIRI• ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING El 99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(PRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 435 TANK FILLED WITH INERT MATERIAL? <br /> gellona <br /> Ely., ❑No <br /> • • Formerly SWRCS Form B <br /> CUPAFORM(4/99) <br />