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UNIFIED PROGRAM CONSOLIDATED FORM 'I <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> T D S 61 02 (N P <br /> Page <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ B.TEMPORARY SITE CLOSURE <br /> (Check ane Aam Dory) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (TT. ..on-/orbcaloa -w (SpaciTy change-brlual use omy) ❑ &TANK REMOVED 430 <br /> BUSINESS NAME(Sema es FACILITY NAME pr DBA-Dcing Bulinus Aa) FACILITY ID 9 <br /> F: <br /> LCCATIONVATHINSITE(OP ona9 <br /> G , l o <br /> I.TANK DESCRIPTION <br /> TANK IDC TANKMANLIFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> II'Yn,mmplele pne page br earA rampartment <br /> DA EINSTALL 0O) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> Sl0 <br /> ADDITIONAL DESCRIPTION(F-11 c vee aMy) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ S.JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1e. REGULAR UNLEADED ❑ 2. LEADED ❑ AVIATION FUEL <br /> (Il marNM,compbro PetmJeum iypa) ❑tn. PREMIUM UNLEADED - ❑ 3. DIESEL 8 <br /> ❑ 2. NON-FUELPETROLEUM 0J MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICALPRODUCT COMMON NAME(ftm Manrtloos M.wmh--meyRoga) CABS(/mm Nezanloos Matanals lent-W page) <br /> ❑ 4, HAZARDOUS WASTE(1 ed M <br /> Used Din <br /> Q 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPEOFTANK ❑ 1. SINGLEWALL ❑ 3.SINGLEWALLWITH ❑ S. SINGLE WALL LMTH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check ons"m-w ❑ 2. DOUBLEWALL ❑ 4. SINGLE WALL IN A VAULT <br /> ❑N. OTHER <br /> TANK MATERIAL-p(knary taM ❑ 1, BARESTEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Checkem Hamonly) ❑ 2. STAINLESS STEEL ❑4. STEEL <br /> PI.AS <br /> CLAD <br /> TRGFRPS ❑ 8. FRP COMPATIBLE WIICO%METHANOL ❑99.OTHER <br /> REINFORCED <br /> TANK MATERIAL-secontlary tank ❑ 1 BARE STEEL ❑ 3. FISERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL 095. UNKNOWN <br /> (Check one Hem ony) ❑ 2.STAINLESS STEEL ❑ 4.RSTEEL CILAD EINFORCED WIFIBERGLASS <br /> (FRP) ❑ 9. FRP NOWCORROMBLE JACKET ❑99, OTHER <br /> ❑10. COATED STEEL <br /> ❑ S.CONCRETE <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING <br /> ❑ S. CUBS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> Oft COATING <br /> El 2.ALKYD LINING - ❑ 4. PHENOLIC LINING ❑B. UNLINED 99. OTHER (Ferlocaloeacn <br /> Chackom Homo ) DATE INSTALLED <br /> OTHERCORRO' ON ❑ 1.MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1395. UNKNOWN 436 <br /> PROTECTIONIFAPPLICABIE PROTECTION ❑99. OTHER__ <br /> ❑ 4. IMPRESSED CURRENT (Forla:al use only) <br /> (Check Dna Hem pMkn ❑ Z.SACRIFICIAL ANODE. <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fork,celoasoMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CheckaHMat RANY) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILLTUBESHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N-TANK LEAK DETECTION. <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER Check ane item ON): <br /> If SINGLE WALL TANK(Check all that app J' <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLEWALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(AM) ❑ 5. VAOOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING <br /> BIENNNLTANKTESTING - 099. OTHER <br /> V.TANK CLOSURE"'FOR" CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRIMOMAY) ESTIMATED OUANTTTY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 9allona ❑Yas ❑Na <br /> CUPAFORM(4/99) FOM <br /> nedy SNRCB Form B <br />