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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (iWo Pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (OMak orN nam mly) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑O.RENEWAL PERMIT (S'.df,...rI lar wa,vee only) (SperdY cnanpa-brlocw use ow ❑ a. TANK REMOVED 400 <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Doing Business As) FACILITY 10 e 1 <br /> la CC �1 <br /> L TION WIT SITE(D a 401 <br /> CA <br /> I.TANK DESCRIPTION <br /> TANK 10• TANK MANUFACTURER COMPARTMENTALIZED TANK EK.. ❑ No <br /> J,:or,-, IPYei,rdnplets we page far eatl mmpa*ML <br /> U <br /> PATE INSTALLED(YEA(LMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Fxbcal use a*) <br /> C. L <br /> IL TANK CONTENTS <br /> TANK USE 402 PETROLEUM TYPE n[ 4 2 <br /> 1. MOTOR VEHICLE FUEL ❑fa REGULAR UNLEADED ❑ 2. LEADED I@ La. T UEL <br /> (n manM,campfele Parmleum Typo) Zi 19. PREMIUM UNLEADED ❑ 0. DIESEL °woTlqNkALTH <br /> Cl 2. NON-FUEL PETROLEUM ❑Ic MIDGRADEUNLEADED ❑ 4. GSOHOL <br /> ❑ 0. CHEMICAL PRODUCT COMMON NAME(Aom Huallom IlNrorials Inwnrorypapal m MalMab Irrum m.Page) <br /> ❑ 4. HAZARDOUS WASTE(In l <br /> Us"Op <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL ❑ 0. SINGLE WALL9BTH ❑ S. SINGLE WALL MTH INTERNAL BLADDER SYSTEM <br /> (Cnack.0R .,M 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ A. SINGLE WALL IN A VAULT 099 OTHER <br /> TANK MATERIAL-pnmary brut T BARE STEEL ❑ 0. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Check peso Mm Ium ❑ 2. STAINLESS STEEL ❑A STEEL CLAD W/FIBERGLASS ❑ 6 FRP COMPATI BLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRPt <br /> TANK MATERIAL-sewrWs,Wk ❑ 1 BARE STEEL 0. FIBERGLASS I PLASTIC ❑ S. FRP COMPATIBLE W IM%MEMANOL 095. UNKNOWN <br /> (Chock oru irom onw ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD W9FIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑W. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3 EPDXY LINING ❑ 5. GLASS LINING ❑95. UNNNOWNOO <br /> ❑ 2. ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 9. UNLINED ❑99. OTHER Fwlopalu»ant) <br /> Check one Mm m ) GATE INSTALLED <br /> OTHER CORROSION ❑ t MANUFACTURED CATHODIC ❑ s. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 4K <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER (Forbcal use an77 <br /> (Check one Ram oruy) ❑ 1 SACRIFICALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fmbcal uaaahly) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check atl mat applyl 1. SPILL CONTAINMENT 1.ALARM O. FILL TUBE SHUT OFF VALVE__ <br /> 2. DROPTUSE ❑ 2. BALLROAT ❑ 4. EXEMPT <br /> 0. STRIKER PLATE <br /> -N.TANK LEAK DETECTION <br /> IP smeLE weLL TANK en.aA w rmu IF DOUBLE WALL TANK OR TANK VATIR BLADDER(CMck em ibm-01P <br /> ❑ 1. VISUAL(EXPOSEDPORTION ONLY) ❑ S. MANUAL TANK GAUGING INTO) ❑ L VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ S. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 5. MANUALMOMTORING <br /> ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR)- ❑ 9. TANKTESTING <br /> BIENNIAL TANK TESTING ❑IK. OTHER <br /> I <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 405 TANK FILLED WITH INERT MATERIAL? � <br /> ga&u,s ❑Yes <br /> ❑Na <br /> FoMerly SV4RCB FOND 8 <br /> CUPAFORM(4199) _ <br />