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.. NIFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (t v pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT 0 C AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> (Check one d.ro only) 0 T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (Spxlfy leaa0n-brlacel use only) (Spealy cha'..Icrece vse only) 0 0. TANK REMOVED 130 <br /> BUSINESS NAME(Sato as FACILITY NAME or DBA-Going 8 'nes.Aa) FACILITY ID 1 <br /> /qq'll 6 <br /> DULA lopq nffmlf�� <br /> Fla . /N. <br /> 1.TANK DESCRIPTION <br /> TANK IDN TANK MANUFACTURER COMPARTMENTALIZED TANK 0 Ye. �No <br /> Ma 1�.,\ a Q . If Nei,complete one page fw mcln mmpa l nent <br /> OATEINSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use 0My1 <br /> II.TANK CONTENTS <br /> TANK USE 032 PETROLEUM TYPE <br /> �1 MOTOR VEHICLE FUEL la REGULAR UNLEADED ❑ Z. LEADED ❑ 5 JET FUEL <br /> (Irmarke0,compete Potmleum Type) Cl Is. PREMIUM UNLEADED 0 3.DIESEL 0 6 AVIATIONFUEL <br /> D 2. NON-FUEL PETROLEUM tc MIOGRADEUNLEADED 0 4.GASOHOL 0 99. OTHER <br /> 0 3. CHEMICALPRODUCTCAS0(Imm Haxamous Materials lnsentOry page) <br /> D 4. HAZARDOUS WASTE(InduOes COMMON NAME(/mm Hazanloui MafeNbinnnfarypage) <br /> Ueen an <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL Cl 3, SINGLE WALL WDH D 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> ,..a EXTERIOR MEMBRANE LINER D 95. UNKNOWN <br /> (Check anelfem only) HI 2. DOUBLEWALL 0 4. SINGLE WALL IN A VAULT <br /> / 099. OTHER <br /> TANK MATERIAL-primary lank D 1 BARE STEEL 03, FIBERGLASS I PLASTIC 0 5. CONCRETE 095. UNKNOWN <br /> (Chock om item any) ❑ 2. STAINLESS STEEL �4. STEEL CUD WIFIBERGLASS ❑ 0 FRP COMPATIBLE W11W%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-socontlary Mnk 0 1 BARE STEEL 0�.y 3. FIBERGLASS I PLASTIC 0 9. FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (Check onei(em only) 0 2, STAINLESS STEEL 1)!4. STEEL CLAD W/PIBERGIASS 0 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 0 10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING D 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING D 95. UNKNOWA433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ e. UNLINED 099. OTHER Fmlocal moon ) <br /> (Check one item o ) DATEINSTALLED <br /> OTHER CORROSION ❑ t. MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REINFORCED FUSTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER (For local use pow(Lhockom item ony) 1-12. SACRIFICIAL ANODE <br /> SPILLANDOVERFIU. YEAR INSTALLED TYPE(Forlocal use ony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that aPpfy) 1. SPILL CONTAINMENT D 1. ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE D 2. BALL FLOAT 0 4, EXEMPT <br /> 0 3. STRIKER PLATE <br /> - N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK jChwk eq that a IF DOUBLE WALL TANK OR TANK WITH BIADOEft Chock me item DR ): <br /> 01, VISUAL(EXPOSEOPORTION ONLY) 05. MANUAL TANK GAUGING(MTG) 01. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> Cl 2. AUTOMATIC TANK GAUGING(ATG) D 5. VADOSEZONE �2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUSATG 0 T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING D99, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(Y"O/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallon. ❑Yes 0 No <br /> CUPAFORM(4199) . . FormeflY SNRtCB Form B <br />