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�NIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (faro pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT �5. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (Check one llampNy) ❑ 7. PERMANENTLY CLOSED ON SIT <br /> ❑3.RENEWAL PERMIT (Speclly reason-hr local Dad oMy) (Spealy change-kr local use on(y) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME ISe...a FACILITY NAME or DBA-O Ong Beainess Aa) FACILITY IDR �' 1 <br /> LOCATION WITHIN SITE(Opfiorup 431 <br /> S G "L& <br /> I.TANK DESCRIPTION <br /> TANK IDM TANK MAN CTURER 1-f�✓ COMPARTMENTALIZED TANK ❑ Yes <br /> 1? /_ ? / f� 11'Yei complete one page lot each compartmen <br /> DATE INSTALLED(YEARIMO) ( L/ TANK CAPACITY IN NS NUMBER OF COMPARTMENTS <br /> V - 9 a- /0) 000 <br /> ADDITIONAL DESCRIPTION(Forlaoal use gnly) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUMTYPE <br /> }]Lt. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑ 2. LEADED 11S.JET FUEL <br /> I. <br /> Aad,complew Fellow.Type) 111h. PREMIUM UNLEADED >. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL 110, OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ COMMON NAME(hem Ha:alloua Mehrials Invenfarypege) CAS p(hem Hezardoua Mefedve <br /> als Inntorypaga) <br /> 4, HAZARDOUS WASTE(/rMudea <br /> Used Oro <br /> 17195 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPEOFTANK ❑ 1. SINGLEWALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL NTH INTERNAL BUDDER SYSTEM <br /> (Check ane dem Dory) X2. DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary lank 1 BARE STEEL 133, FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Chackmed.rt.nly) ❑ 2_ STAINLESS STEEL X4, STEEL CUD W/FISERGUSS ❑ B. FRP COMPATIBLE W/100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondarylank EJ 1 BARE STEEL ❑ 3. FIBERGLASS/PUSTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL 13 95, UNKNOWN <br /> (Check one dem onW ❑ 2. STAINLESS STEEL STEEL CUD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> ❑ <br /> S. CONCRETE <br /> TANK INTERIOR LINING D 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 1195. UNKNONM433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING UNLINED ❑99. OTHER Forbcal me on ) <br /> Chock aro dem onl) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PUSTIC ❑95. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE NLIEnz- <br /> PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 'love, OTHER <br /> (Chock one item only) ❑ 2. SACRIFICIAL ANODE (Forlocaluseonly) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use poly) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check aha that apply) 1. SPILL CONTAINMENT ] ❑ 1. ALARM FILL TUBE SHUT OFF VALVE 212- <br /> DROPTUBE P ❑ 2. SALL FLOAT 4. EXEMPT <br /> STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all Ural a IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check ono dam On)Y): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING ' <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3, MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> NA !T gallons ❑yea o C <br /> CUPAFORM(4/99) Formerly SVJRCS Form B <br />