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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Page <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ a. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (Check one Mm any) ❑ T, PERMANENTLY CLOSED ON SITE <br /> ❑I.RENEWAL PERMIT (Speciy maonrorlacaluv arvYl fSpecly coupe-rorlocM vas prvYl ❑ a, TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Cps,Business As) FACILITY 10 0 1 <br /> C 4 <br /> LOGTION VATHIN$ITE(Opliona7� <br /> T r, <br /> I.TANK DESCRIPTION <br /> TANK IDs TANK MANUFACTURER M RT TJI3 ANK Yes ❑ No <br /> 'T`OD D Is" <br /> DATE <br /> FoIln one page tar aso wmpanmenL <br /> �l 1 _., <br /> DATE INSTALLED(YEARJMO) TANK CAPACITY IN GALLONS U -'NUMBER OF COMPARTMENTS <br /> Q U U <br /> ADDITIONAL DESCRIPTION(Fwlocal use any) <br /> it.TANK CONTENTS HM Inu i' J TANK USE 432 PETROLEUM TYPE PE <br /> 1, MOTOR VEHICLE FUEL ❑is. REGULAR UNLEADED ❑ 2. LEADED ❑ I. JET FUEL <br /> (IrneAeO,complete Pahaleum Type) ❑Ib PREMIUM UNLEADED D. DIESEL ❑ 8. AVIATIONFUEL <br /> ❑ 2. NON�FUELPETROLEUM 0 1 MIOGRADE UNLEADED ❑ a GASOHOL ❑N OTHER <br /> ❑ 2. CHEMICALPRODUCT CASe(APm NanNaua Mafedab Intent <br /> ❑ A. H RDOUSWASTE(Ioe*xfoa COMMONtUME(ham HalaNaw Mafenala lnr.nforypge) orypa9a) <br /> Usec De) <br /> 95 Ummuom <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 0. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADOER SYSTEM <br /> (Coach om Mm ny) 2DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95 UNKNOWN <br /> a . <br /> ❑ a. SINGLE WALL INA VAULT ❑99 OTHER <br /> TANK MATERIAL-pmaryenk 1 BRAE STEEL ❑ D. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 0 0. UNKNOWN <br /> (CMtk ene"...w ❑ 2. STAINLESS STEEL ❑ a. STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE WHDDYe METHANOL 099. OTHER <br /> REINFORCED FUSTIC(F0.P, <br /> TANK MATERIAL-Mrnrbay lank ❑ 1 BARE STEEL 5. FIBERGLASSIPLASTIC ❑ e. FRP CCMPATIBLE W?IM%METHANOL 095. UNKNOWN <br /> fChackan item oNyl ❑ 2. STAINLESS STEEL ❑ a. STEEL CLAD WIFIBERGLASS ❑ B FRP NONCORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10 COAT_D STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ D. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN432 GATE INSTALLED <br /> OR COATING <br /> ❑ 2 ALKYD LINING ❑ A. PHENOLIC IJNING ❑ B. UNLINED 099. OTHER (Fa/IacAwaaM) <br /> nenllore Aemo ) <br /> OTHER CORROSION DATE INSTALLED <br /> PROTECTION IF APPLICjn11 <br /> CTURED CATHODIC ❑ 0. FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN e2A <br /> ION ❑ a. IMPRESSED CURRENT ❑99 OTHER <br /> (Check 0e 0em any) IALAHODE (Farbcal we Only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(FarlacL use any) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check a that appy) ONTAINMENT 1. ALARM 1 FILL TUBE SHUT OFF VALVE <br /> UBE 2 BALL FLOAT ❑ A. EXEMPT <br /> PUTE <br /> -N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Gllaak kl lMfa IF Og1BLE WALL TANK OR TANK WITH BLADDER Cneak are ibm DNA:_ <br /> ❑ 1, VISUAL(EXPDSEDPORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTC) t. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING ' <br /> ❑ 5. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 0. MANUALMONITCRING <br /> ❑ a. STATISTICALINVENTORYRECONCILIATION(SIR)• ❑ 5. TANKTESTING <br /> BIENNIAL TANK TESTING ON. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(Y'RIMO,OAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 9aao^e ❑Yea ❑No <br /> CUPAFORM(4199) - Formerly SWRCS Fom+B <br />