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Adak Ah <br /> INl D PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (We pages per lank) <br /> ���••• Page _ or <br /> TYPE OF ACTION ❑T NEW SITE PERMIT 0 4. AMENDED PERMIT . CHANGE OF INFORMATION) ❑ 5. TEMPORARY SITE CLOSURE <br /> (Check am Tem only) 0 ?. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Spe*neason-brlocal use may) (Specry,chinge-lorlocal use only) D 8, TANK REMOVED 430 <br /> BUSINESS NAME(Sameas FACILITY NAME or DBA.DD^oinng�BUNneas As) FACILITY ID <br /> u <br /> LOCATION WITHIN SITE(Oph'omg 431 <br /> sf 5 d <br /> I.TANK DESCRIPTION <br /> TANK IDM /� TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Vas <br /> No <br /> ® / 9/ 2 _ // R Q� If'Yea,mmplMe one page ror goh co a ent. <br /> DATE INSTALLED(YEANI <br /> RO) TANK✓CAPACI "MONS NUMBER OF COMPARTMENTS <br /> -9 ;', lO oov <br /> ADDITIONAL DESCRIPTION(Furlxal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> MOTOR VEHICLE FUEL >9a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (Ilmo4seemmpleMPtQnbum Type) 01b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8.AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 111. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> D 3. CHEMICAL PRODUCT <br /> 04. HAZARDOUS WASTE(Inefoles COMMON NAME(Nom HazaMous Materials lnwnlorypage) CASY(ham Nazareaus Memorials lnuenmerypaga) <br /> UssC Cif) <br /> 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 11, SINGLE WALL 0 3. SINGLE WALL WITH 0 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Chackom Bet only) D/;, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> X D 4. SINGLE WALL IN A VAULT 11 as OTHER <br /> TANK MATERIAL.pnmary lady D 1 BARE STEEL ❑ 1 FIBERGLASSIPLASTIC ❑ 5. CONCRETE 1:195. UNKNOWN <br /> (Check one item only) 112. STAINLESS STEEL x4. STEEL CLAD WIFIBERGIASS 08. FRP COMPATIBLE W IM%METHANOL 1199.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-samnd.q tank D 1 BARE STEEL D 3. FIBERGLASS/PLASTIC 0 e. FRP COMPATIBLE WHDD%METHANOL 095. UNKNOWN <br /> (Check one item oltty) 0 2, STAINLESS STEEL X4. STEEL CLAOWIFIBERGLASS 09, FRP NON-CORRODIBLE JACKET 1199. OTHER <br /> REINFORCED PLASTIC(FIRE) 1110. COATED STEEL <br /> 0 S. CONCRETE <br /> TANK INTERIOR LINING D 1. RUBBER LINED 0 3. EPDXY LINING 0 S. GLASS LINING 1195. UNKNOWN433 DATEINSTALLED <br /> OR COATING <br /> 112.ALKYO LINING 0 L PHENOLIC LINING UNLINED 099. OTHER <br /> Cheek om Rem onl Forlocal use on <br /> OTHER CORROSION D 1. MANUFACTURED CATHOOtC D 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPUCABLE PROTECTION <br /> ❑ d. IMPRESSED CURRENT 099. OTHER <br /> (CMckom iNm only) ❑ 2. SACRIFICIAL ANODE I (Forlocal usa ony) <br /> SPILL AND OVERFILL YEARINSTALLED TYPE(For tical use a*) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that apply) 11 1. SPILL CONTAINMENT_ Q/ ❑ 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 2, DROP TUBE .�� 0 2, BALL FLOAT 0 4. EXEMPT <br /> 0 3. STRIKER PLATE �7 <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check ad that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUCUSATG ❑ T. GROUNDWATER 0 3. MANUALMONITORING <br /> D 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 8. TANKTESTING <br /> BIENNIAL TANK TESTING 1199. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE�LAST USED(YRMO/OAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> Ballona /.' <br /> ❑Yas No U. <br /> 1/I a/a�lo� <br /> CUPAFORM(4/99) ( / Formerty SWFtCB Forrn B <br />