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DIED PROGRAM CONSOLIDATED FOIv - TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page 35 01743 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chock only nem only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3RENEWAL PERMIT ® ❑ 8TANK REMOVED BUSINESS NAME(Bunn as,FACILITY NAME or DBA-nouns Business As) 3 FACILITY ID: t AMERICAN MOULDING&MILLWORK FA0003555 LOCATION WITHIN SITE(othaan 4 PHONE 1{J I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency. '`y11,1 T 1�ID# t 1 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑Na 4)4 ,f} ©1 Z � If"Yes",c kte one a for each w t. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS ADDITIONAL DECRIPTIO (Fw kcal use only) 4 I 1 SGL II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 449 ❑ I.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (Ifmarked cwsylete Pamkum Type) ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ le.MIDGRADE UNLEADED ❑ 4.GASOHOL ® 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Baaardous Matensh Invento n Page) 441 CAS#(rrom xaudoas Mataia6 mventoq page) 442 El 4.HAZARDOUS WASTE (Ialudea Used oil) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chat town kern only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑ 2.DOABLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Check ow hem only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FBERGLASS ❑ 8.FRP COMPTBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Cheek ow nom only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ S.CONCRETE TANK O CR ITER OR LINING El 1.RUBBER LINED El3.EPDXY LINING El5.GLASS LINING El95.UNKNOWN 446 DATE INSTALLED 4,17 ING (Check one am only) ❑2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99.OTHER (For bd use aNy) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item o*) ❑4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2 SACRIFICIAL ANODE (Fw kcal use oNv) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local uae only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (CTcck A that ally) ❑ 1 SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE ❑ 2DROP TUBE ❑ 2BALL FLOAT ❑ 4EXEMPT ❑ 3 STRIKER PLATE IV.TANK LEAK DETECTION IA desoiptbn ofthe monitoring grog shall be submitted to the IoW•genry) IF SINGLE WALL TANK(Check all that apply) 453 1F DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSEDPORTIONONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Chcokone hem only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING ❑ 3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 452 Ilons ❑ Yes ❑No UPCF(12/99 revised)