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AM <br /> NIFIED PROGRAM CONSOLIDATED FORMwM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (twopagespertank) <br /> /���([ Page _ or _ <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4, AMENDED PERMIT // _J CHANGE OF INFORMATION) 0 B. TEMPORARY SITE CLOSURE <br /> (Check am ihm only) �� -- lZ z ogv j -�/ ❑ y. PERMANENTLY CLOSED ON SITE R <br /> 03.RENEWAL PERMIT (Spec#yresson-brloml use only) (S/pecNy4-�cM�-npe--b/r lVoW um o/MHKn Y <br /> ❑ B. TANK REMOVED 490 I <br /> BUSINESS NAME(Sema as FACILITY NAME or DBA-Doing Business As) FACIUTY IDN <br /> LOCA Waxy <br /> ptiansp 43t <br /> C <br /> 1.TANK DESCRIPTION <br /> TANK IDN.�y TANK MANUFACTURER COMPARTMENTALIZED TANK as 0 No <br /> T+- it-Yaa',complete one page for each compa toent. <br /> DATE INSTALLED(YEAWMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 012 <br /> ADDITIONAL DESCRIPTION(Forbcal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ,�_,,// <br /> ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED Np,l LEADED ❑ 5. JET FUEL <br /> (Nmarkaq complab Petmlaum Type) ❑lb. PREMIUM UNLEADED 0 3. DIESEL ❑ B. AVIATIONFUEL <br /> 0 2. NON-FUEL PETROLEUM 01a. MIDGRADE UNLEADED 0 4. GASOHOL ❑99. OTHER <br /> 0 3.CHEMICALPRODUCT <br /> ❑ 4. HA]ARDOUSWASTE(lncI COMMON NAME(hum Hazar#oua Materials lownrorypaps) CAS#(/mm Hazantam Materials lnwnforypsye) <br /> ume Dip <br /> 1195 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 0 1, SINGLE WALL 0 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Checkamltamanly) 0 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 4. SINGLE WALL IN A VAULT <br /> ❑M. OTHER <br /> TANK MATERIAL-primary tank 0 1 BARE STEEL 0 3, FIBERGLASS/PLASTIC 0 5, CONCRETE 0 95. UNKNOWN <br /> (Checkoheil,NI ❑ 2. STAINLESS STEEL 0 4. STEEL CLADWiFIBERGLASS 0 8. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REINFORCED PIASTIC FRP) <br /> TANK MATERIAL-mcon4ary tank 0 1 BARE STEEL 0 3. FIBERGLASS/PLASTIC 0 B. FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (Check acre item only) 0 2. STAINLESS STEEL 0 4, STEEL CLAD WTIBERGLASS 0 8. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER UNED 0 3. EPDXY LINING 0 S. GLASS LINING 095. UNKNOM433 DATEINSTALLED <br /> OR COATING <br /> 132. ALKYD LINING 0 4, PHENOLIC LINING 0 8, UNLINED 099. OTHER <br /> (Check om ihm only) 13 <br /> use,only <br /> OTHER PROTECTION <br /> IF ON 0 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION 04. IMPRESSED CURRENT 099. OTHER <br /> (Check one item only) 0 2. SACRIFICIAL ANODE (Forlocal use oMy) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocalumanl,) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that appy) 0 1 SPILL CONTAINMENT ❑ 1. ALARM 0 3. FILL TUBE SHUT OFF VALVE_ <br /> 0 2. DROP TUBE ❑ 2. BALL FLOAT 0 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK fCheok all that, ): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check acre item only: <br /> 0 1. VISUAL(EXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 B. VADOSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER 0 3. MANUALMONITORING <br /> 04. STATISTICAL INVENTORY RECONCILIATION(SIR) 08. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> 1199. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YWMOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 7NK FILLED`MTH INERT MATERIAL? <br /> gallon, 0 Yea 0 No <br /> CUPAFORM(4/99) • ' Formerly SVVRCB Form B <br />