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L,`:IED PROGRAM CONSOLIDATED FOI. TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) PW 39 or 43 TYPE OF ACTION ❑ INEW SITE PERMIT ❑ a:AyIL'SDI'U PL'I2yIIT ❑ II:UGr.(I-I[1-oKb14fION ❑ 6TEMPORARY SITE CLOSURE (Chock only nem Only) I nae only) (Spec!� evon-i local use onlvp. El PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT ❑ S TANK REMOVED 430 BUSINESS NAME(Sameas FAC11,ITYNAMEor DBA-Doing Business As) FACILITY ID: AMERICAN MOULDING&MILLWORK 3 FA0003555 LOCATION WITHIN SITE(ophonou AQ PHONE ' 1.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall he submitted to the local agency. TA)K IDN432 TANK MANUFACTURER 413 COMPARTMENTALIZED TANK Yes No {)) ❑ ❑ U UI If"YO",co kte one a for each DATE INSTALLED(YEAR/MO) 411 TANK CAPACITY IN GALLONS 431NUMBER OF COMPARTMENTS a 600 ADDITION41,DESCRIPTION F.tical use only) I II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ❑ 1.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (IfmvkW congkte Pewleum Typo) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ b.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ In.MIDGRADE UNLEADED ❑ 4.GASOHOL ® 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME 6om Haardous Materials Invmt CASH from xe�a�dous Mzmria6 lnvento page) ❑ 4.HAZARDOUS WASTE ( °fy p0ge) 041 ( ryP 8 ) aaz (Iocludes used oa) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one hem only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one hem onty) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/I ODYo METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Clack one sum only) ❑2.STAINLESS STEEL ❑ 4.STEEL CLAD W/TIBERGLASS ❑ S.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL [:199.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑ 95.UNKNOWN 44a DATE INSTALLED 447 OR COATING (Check one dem oely) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99.OTHER For tical use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 443 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one nom only) ❑ 2 SACRIFICIAL ANODE [:14 IMPRESSED CURRENT El99 OTHER (Far boil use anty) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Cgs a(hu wl,) ❑ 1 SPILL CONTAINMENT ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE ❑ 2DROP TUBE ❑ 2BALL FLOAT ❑ 4EXEMPT ❑ 3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of monionng program shall be submhted to the IoW agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (O Ck mss item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK 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? 457 gallons ❑Yes ❑ No UPCF(12/99 revised)