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NIFIED PROGRAM CONSOLIDATED FOR oZ J' 1L� TANK: l/ UNDERGROUND STORAGE TANKS — TANK P CCCCV/( PR N: Z 7! if7 FAC q: (two peg/per tank) TYPE OF ACTION �( � (Cheek only item only ❑ INEW SITE PERMIT ❑ 4 AMENDED PERMIT 5 CIIANGC OF INFORMATION � 2of3 EMPORA7 kg gyp /p/)ge ❑IRENEWAL PERMIT {' Nm°s°n'lurlaesl mcoiJy) (6pcurymso" fodmel isc°Fly) ❑ ]PbRMA177T CED NIB{rg_ BUS ESS NAME�(Syney FACILITY NAME or DBA Doing Boniness Al FACILITY ID ❑S TANK REMOVED 430 4 3 PR q: 1 L CATION N7pTHIN SITE(O ..a4 Irtg 1-4 Cc O �c h`� U( . NE ?,d 431 I.TANK DESCRIPTION(A scaled plot plan with the location of I h: UST system including baildin s and landmarks shall be sOubmitt tothe—`j 6Z— O TANK IDN 432 TANK MANUFACTURER B B YJ — ei� U'Aj IV—U c��'"1 433 COMPARTMENTALIZED TANK 6" ❑Yes ❑No 434 DATE INSTALL O) 43s TANK CAPACITY IN GALLONS If'Yes'",template one page for each°°mpanmwt �..��,� 436 NUJMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(For local vae only 438 USED.TANK CONTENTS 439 PETROLEUM TYPE .MOTOR VEHICLE FUEL ❑ In.REGULAR UNLEADED (If madad complem Pctmleom Tye ❑2.LEADED ❑ S.JET FUEL 440 ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 2.NON-FUECHEMICAL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑".OTHER 6. FUEL ❑ 1.CHEMICAL PRODUCT ❑4.GASOHOL ❑ ".OTHER ❑ 4.HAZARDOUS WASTE COMMON NAME(ft.Hnda nos Materials m.enary Pgh CASH f P B ) 441 (mm HvaNaos Mmenals Invemm� a e (Includes Uaed Oi) 442 ❑95.UNKNOWN DI.TANK CONSTRUCTION TYPE OFTANK Ol SINGLE WALL ❑ 3.SINGLE WALL WITH (Cheek one item on EXTERIOR MEMBRANE LINER ❑95 UNKNOWN 443 WITH MTERNALBLADDER SYSTEM 443 El 2.DOUBLE WALL 5.❑ 9UNKNOWN �.r ❑ 4.SINGLE WALL M VAULT ❑99,OTHER TANK MATERIAL-pnmary tank >_I I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE E195,UNKNOWN (Check one i.em nay ❑ 2,STAINLESS STEEL444 ❑ STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/100°A METHANOL REINFORCED PLASTIC(FRP) TANK MATERIAL- ❑ 99.OTHER secondary lank ❑ 1�kf1E STEEL ❑3.FIBERGLASS/PLASTIC (Check onelam onl) LTJ/ ❑ S.CONCRETE ❑9S UNKNOWN 445 2.STAINLESS STEEL ❑ R INFO CED PLASTIC(FR ) ❑ 8.FKP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(PRP) El S.CONCRETE ❑ 10.COATED STEEL ❑99.OTHER TANK INTERIOR LINING OR COATING ❑ I.RUBBER LINED ❑ 3.EPDXY LINING ❑ LG 95.UNKNOWN 446 DATE INSTALLED 447 (Cheek ane itemony ❑ 2pLKVD LINING El4 PHENOLIC LINING ❑ 6 6 UNLINED OTHER OTHER CORROSION ❑ I MANUFACTURINGCATHODIC (For loyoaonl9 PROTECTION IF APPLICABLE PROTECTION ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN❑ 449 (Check one iam ony ElOIMPRESSED CURRENT 25 ORIFICIAL ANODE ❑ 990THER 448 DATE INSTALLED SPILL AND OVERFILL YEAR INSTALLE450 (Farloeel only ( TYPE(loraluxony 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED Cheek all my ly ❑ MMENT 452 P TUBE ❑ IALARM LL TUBE SHUT OFF VAL` 3 STRIKER PLA r )--.— ❑ 2 BALL 4 EXEMPT FLOAT dPa°"°cmc mammon IFSMGLE WALL TANK(CM1eQ ell��dwN.TANK LEAK DETECTION(Ad... °�ply BPmgram 4hBl be aubmittadamelocd egcojy ❑ IVlSUAL(EXPOS Ppg'r�19'6 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER /TGG77AA'''^� NLY)If El5 MANUAL TANK GAUGING(MTG) (Cheekoneiamony 454 ❑ 2AUTOM I UDING AT ❑ 6VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 T�US ATG ❑ ]GROUNDWATER ❑ 4S TISTICAL INVENTOR 0 ILIA17 N ❑ STANK TESTING ❑2CONTIIY000 B(1'E ST/('f4y1•'+`�sONTfORMC (SIR)BIENNIAL TANK TES NG ❑3 MANUAL M/ `ITLORO' ❑99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE_LA^ST USED 0' /DAY) 455 ESTIMATED QU NTITY OFSUBSTA CE REMAINING 456 U-* l� ( ( a(N �.^O ^ TANK FILLED WITH INERT MATERI L7 457 V`N [_/`Li Py ❑Yea No UPCF(12/99 revised)