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rIIFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> ((vm pages per tank) <br /> Page <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4. AMENDED PERMIT O 5. CHANGE OF INFORMATION) D T.TEMPORARY <br /> SITE <br /> ELOSED CLOSURE SITE <br /> (Check erle item enty) <br /> 03.RENEWAL PERMIT (S pyreason-lor lwal use Dray) (Seedy chenps-Nrlo lme.11) D B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as F//AGILITY NAME or DBA-DOIw Business Aa) <br /> FACILITY ID a I <br /> LOCATION WITHIN SITE("peon", 431 <br /> d90 <br /> I.TANK DESCRIPTION <br /> TANK IDM TANK MANUFACTURER COMPARTMENTALIIEO TANK D Yes No <br /> w<34 <br /> 1'0� w C��' "'Yes"wmplete me page lar eaN wmpanmenL <br /> DATE INSTALLED(YEARAIO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> tq�7 12 <br /> ADDITIONAL DESCRIPTION(For lwal vas ody) <br /> II.TANK CONTENTS <br /> TANKUSE 432 PETROLEUM TYPE 132. LEADED O 5 JET FUEL <br /> ISI 1 MOTOR VEHICLE FUEL D te. REGULAR UNLEADED <br /> 11 marled,complala Pwrolaum Type) F�10. PREMIUM UNLEADED D 3. DIESEL ❑ S. AVIATION FUEL <br /> 112. NON FUEL PETROLEUM D tc MIDGRADEUNLEADED D 4.GASOHOL ❑99. OTHER <br /> 0 3.CHEMICAL PRODUCT COMMON NAME(hvm HasaMom MaM1tlals Imenlorypage) CAS a(Imm Haxadove Maf rials Inaenfary page) <br /> 0 4. HAZARDOUS WASTE(ImFludes <br /> Used Oi) <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 01. SINGLE WALL D 3. SINGLE WALL WITH D 5. SINGLE WALL WITH INTERNAL BLAOOER SYSTEM <br /> ddda EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Check pm Ram IIrW ¢A 2. DOUBLE WALL 04, SINGLE WALL IN A VAULT <br /> I ❑99. OTHER <br /> 095UNKNOWN <br /> TANK MATERIAL-primary Mnk D 1 PARE STEEL III❑UUU 3. FIBE0.GUSSIPLASTIC ❑ 5. CONCRETE . <br /> (Check ons dem eMy) ❑ Z. STAINLESS STEEL ®4. STEEL CLAD WIFIBERGLASS 00 FRP COMPATIBLE Wil 00%METHANOL 099. OTHER <br /> r REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank D 1 BARE STEEL O�A 3. FIBERGLASSIPLASTIC D 5. FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (OhecFonalfemoMy) D 2, STAINLESS STEEL tl4. STEEL CLAD WIFIBERGLASS 09, FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> ❑ 5. CONCRETE <br /> ❑ 5CUSS LINING ❑95. UNNNOWNO] GATE INSTALLED <br /> TANK INTERIOR LINING O 1. RUBBER LINED ❑ 3. EPDXY LINING , <br /> . <br /> OR COATING <br /> ❑ 2. ALKVO LINING ❑ 4. PHENOLIC LINING ❑ S UNLINED 099. OTHER (Forbcal use on ) <br /> Check orw Ham o DATE INSTALLED <br /> OTHER CORROSION 0 1. MANUFACTURED CATHODIC O 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 99 OTHER 'Forlocal vsa pmy) <br /> (ChackomiMmonty) O 2, SACRIFICIALANODE <br /> YEAR INSTALLED TYPE(Ferlwal use onty) OVERFILL PROTECTION EQUIPMENT'.YEAR INSTALLED <br /> SPILLANO OVERFILL <br /> ll q�rww h <br /> (Check al lhaf appy) ❑ 1. SPILL CONTAINMENT 0 1. ALARM D 3. FILL TUBE SHUT OFF VALVE <br /> D 2. DROP TUBE 0 2. BALL FLOAT_ D 4. EXEMPT <br /> 0 3. STRIKER PLATE <br /> Pl.TANK LEAK DETECTION ` <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER fChmck mw dem ONO <br /> =(�SEDZRTION <br /> LE WALL TANKCIokag that ): <br /> XPOSEDPORTION ONLY) 5. MANUALTANK GAUGINGMTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLYI <br /> IC TANK GAUGING(ATG) S. VADOSEZONE D 2. CONTINUOUS INTERSTITIAL MONITORING <br /> OUS ATG D T. GROUNDWATER D 3. MANUAL MONITORING <br /> CAL INVENTORY RECONCILIATION(SIR) O B. TANK TESTING <br /> L TANK TESTING Ogg. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> 4 H INERT MATERIAL? <br /> ]5 <br /> ESTIMATED DATE ST USED ESTI MATED QUANTITY OF SUBSTANCE REMAINING TANK FILlE0 N1T <br /> U <br /> gallons D Yes ON. <br /> Formerly SVVRCB Form B <br /> CUPAFORM(4199) <br />