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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (M•o pages per tank) <br /> Page _ DI <br /> TYPE OFACTION ❑1.NEW SITE PERMIT D 4. AMENDED PERMIT D 5. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (Check am item only) D T, PERMANENTLY CLOSED ON SIT <br /> ❑3.RENEWALPERMIT Swdf,meson-lorkolgee anty) (Specycbnpe-A,,T useony) B. TANK REMOVED 430 109 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Swlnefa As) FACILITY IDN .a `�,. 1 <br /> /l1gC <br /> LOCATION VSTIM SITE(Opliop, 431 <br /> L <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK D Yee <br /> om <br /> If•Yee-.complete ane Page fp each oompamnenl. <br /> DATEINSTALLED(YEAR/MO) TANK CAPACITYIN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(F-Ilwal um anM <br /> If.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL D 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (llmaMeQ complele Pefmleum Type) D It, PREMIUM UNLEADED D 3. DIESEL ❑ 0, AVIATION FUEL <br /> D 2. NON-FUELPETROLEUM D to. MIDGRADEUNLEADED D 4. GASOHOL D 99. OTHER <br /> D 3.CHEMICAL PRODUCT <br /> ❑ 4. MAIAROOUS WASTE(Intludes COMMON NAME(Fora Haaamloos Maletlals Imanforypegol CAS N Isom Hazardous Materials Im oton,page) <br /> Used 010 <br /> 0 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK �D 1. SINGLEWALL D 3. SINGLE WALL NTH ❑ 5. SINGLEWALLW1TH INTERNAL BUDDER SYSTEM <br /> .1"� <br /> (Check one item only) 3. DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4.SINGLE WALL INA VAULT [ISO OTHER <br /> TANK MATERIAL-primary tank D 1 BARE STEEL . FIBERGUSS I PLASTIC D 5. CONCRETE D95. UNKNOW11 <br /> (CMck we item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CUD WIFIBERGLASS D B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PUSTIC(FRP) <br /> TANK MATERIAL-secondary lank 1 BARE STEEL 3. FIBERGLASS/PLASTIC D e. FRP COMPATIBLE W11 W%METHANOL ❑95. UNKNOWN <br /> (Cnem*waltemonly) ❑ 2. STAINLESS STEEL ,D 4. STEELCUDWIFISERGUSS D 9. FRP NON-CORRODIBLE JACKET 1399. OTHER <br /> REINFORCED PLASTIC(FRP) 1110. COATED STEEL <br /> ❑ <br /> S. CONCRETE <br /> TANK INTERIOR LINING1. RUBBER LINED ❑ 3. EPDXY LINING D 5. GLASS LINING D as. UNKNOM433 GATE INSTALLED <br /> OR COATING �+ <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING NL B. UNLINED ❑99. OTHE0. Forlocnl uss crit) <br /> Check pyre ism on , ` <br /> OTHER CORROSION D 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT A. OTHER IJ71AL l <br /> (Check one#em only) ❑ 2.SACRIFICIAL ANODE I (Farlocal we Doty) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fprlocalua.wy) OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED <br /> (Checkatl Melapply) D 1 SPILL CONTAINMENT D 1.ALARM D 3. FILL TUBE SHUT OFF VALVE <br /> D 2. DROP TUBE D 2. SAUFLOAT D 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK heck all thefa ), IF DOUBLE WALL TANK OR TANK WITH BUDDER(Chack one item oM <br /> D 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUALTANK GAUGING(MTG) ❑ 1. VISUAL(SINGI.E WALL IN VAULTONLY) <br /> D 2. AUTOMATIC TANK GAUGING(ATG) ❑ 0. VNDOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> D 4. STATISTICALINVENTORYREOONCILIATION(SIR)+ 08. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USEED(YRs�tTOlDDAY) ESTIMATED QUANTITY OF SUBST NCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> / a(e- 0-0 gallons DY.s a <br /> CUPAFORM(4/99) - '' Formedy SVJRCB Form B <br />