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=UNDERGROUND <br /> EDP ROGRAM CONSOLIDATED FORM <br /> JAN <br /> STORAGE TANKS-TANK PAGE 1 ` l <br /> (AYa pages per tank) <br /> Page _ at <br /> ❑ S. TEMPORARY SITE CLOSURE <br /> TYPE OFACTION <br /> dam ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) D T PERMANENTLY CLOSED ON SITE <br /> (Lhxk one Rem Only) <br /> ❑3.RENEWAL PERMIT (SpeN/ynason-{arloul use arxy) (Speuy chergs-brlocalum only) ❑ O.TANK REMOVED 430 <br /> 1 <br /> BUSINESS NAME(Same a FACILITY NAME or DBA-Doing Business/a) FACILITY IDN <br /> LOCATION WITHIN SITE(Opliamp 431 <br /> I.TANK DESCRIPTION <br /> TANKIOtl 1 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Ves ❑ No <br /> C5/ It WeY,rcmplete one page for sash wmpamnent. <br /> TANK CAPACITY <br /> ) <br /> - / IN GALLONS NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEA Rrt40)) / <br /> Q <br /> ADDITIONAL DESCRIPTION(Farksal use arNy) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> D 1. MOTOR VEHICLE FUEL Ell. REGULAR UNLEADED D 2. LEADED <br /> (rymaMW,mmphte Pelmteum Typo) 015. PREMIUM UNLEADED <br /> - :DIESEL ❑ 6. AVIATION FUEL <br /> D 2, NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL 099. OTHER <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(Imm HazaNpus Materiels In nanterypage) CAS N(lmm Hazanfous Meledals inwnterypage) <br /> D 4. HA RGOUS WASTE llalutlas <br /> Used Oig <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK D 1. SINGLEWALL D 3. SINGLEWALLVATH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER [195 UNKNOWN <br /> (Check one Ram ony) ❑ 2. DOUBLEWALL D 4. SINGLE WALL IN A VAULT 099. OTHER <br /> TANK MATERIAL-primary tank 1. BARE STEEL D 3. FIBERGLASS I PLASTIC 05. CONCRETE ❑95. UNKNOWN <br /> (Cwk arm item ony) D 2. STAINLESS STEEL D 4. STEEL CLAD (BERGS D S. FRP COMPATIBLE WH00%METHANOL ❑99. OTHER <br /> REINFORCED PI (RP <br /> TANK MATERIAL-secondary lank D 1 BARE STEEL D 3. FIBERGIASSIPLASTIC ❑ e. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one item-W D 2. STAINLESS STEEL D 4. fFIBER S 90 RP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED (FRP) D <br /> D 5. CONCRETE <br /> DATE INSTALLED <br /> TANK INTERIOR LINING D 1, RUBBER LINED D 3, EPDXY LINING D 5, GLASS LINING D 95. UNKNOWN433 <br /> OR COATING <br /> ❑ 2.ALKVO LINING ❑ 4. PHENOLIC LINING ❑ e. UNLINED 99, OTHER FMEINSTean <br /> Check arm item an DATE INSTALLEC <br /> OTHER CORROSION D 1. MANUFACTURED CATHODIC D 3. FIBERGLASS REINFORCED PLASTIC ❑85. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (For local use only) <br /> (Check am item Only) ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EOVIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forbcal use ony) <br /> (Check an that appy) ❑ 1. SPILL CONTAINMENT D 1. ALARM _ D 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT D 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item on <br /> IF SINGLE WALL TANK(Ghack all that 42 ) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) D 5, MANUAL TANK GAUGING7[1 1, VISUAL(SINGLE WALLIN VAULT ONLY) <br /> D 2. AUTOMATIC TANK GAMING(ATG) ❑ 6. VADOSEZONE D 2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUSATG. - D T. GROUNDWATER D 3. MANUAL MONITORING <br /> D 4. STATISTICALINVENTORY RECONCILIATION(SIR). ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING ❑e9. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENTCLOSURE IN PLACE <br /> ESTIMATED DATEL h(YRIMO/DA`O <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons D Yes D No <br /> • • 1 Formerly SWRGB'F "B <br /> CUPAFORM(4/99) <br />