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L �K <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> jAbLKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 161 <br /> (Mro pa9er rank) <br /> Peg. _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGEOF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (Check Me item only) ❑ PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Swwyrwson-forlocal use only) (Spec+(y charge-rorbW use only) B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing BU3inem As) FACILITY ID 0 1 <br /> �.�.G <br /> L ATION THIN SITE(Op one <br /> I.TANK DESCRIPTION <br /> TANK 100 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Y., No <br /> /A // <br /> D /_ If'Yaa',complebonapegaloreatl�wmp nrr: t. <br /> DATE INSTALLED(YEAR/MO) lY TAN CA ACITY N GAL ONS NUMBER OF COMPARTMENTS <br /> / - looao -r <br /> ADDITIONAL DESCRIPTION(Forbeal use only) <br /> S <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL To. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If.4"all compM1M1 Pefmbum ryp.) ❑1p. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATIONFUEL <br /> ❑ 2. NON-FUEL PETROLEUM MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICALPRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(bom Hazallous Malehals bwnIoq Page) CAS M(1 Hasaldow Maledals Inwnmry page) <br /> Used Oip <br /> 0 95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLEWALLVATH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check one item only) .H 2. DOUBLEWALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> 1 ❑ 4. SINGLE WALL IN A VAULT [IN OTHER <br /> TANK MATERIAL-primary tank ❑ 1. BARESTEEL 3. FIBERGUSSIPLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (CMck.d.nanly) ❑ 2. STAINLESS STEEL ❑4. STEELCUDW/FIBERGUSS ❑ e FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PUSTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARESTEEL 3. FIBERGLASS I PLASTIC ❑ B. FRPCOMPATIBLEWI100%METHANOL 095. UNKNOWN <br /> (Checkaneilemonly) ❑ 2. STAINLESS STEEL ❑ 4, STEELCUDWIFISERGUSS ❑ 9 FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PUBIC FRP) 1110. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER UNE? ❑ 3. EPDXY LINING ❑ 5 GLASS LINING 095. UNKNOWN433 DATEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LININGS UNLINED ❑99. OTHER <br /> (Check ons,iMm on ) Forkxal use on <br /> fyl <br /> OTHER CORROSION ❑ t. MANUFACTURED CATHODIC 1013. FIBERGUSS REINFORCED RUSTIC ❑95. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 9. OTHER (Forbcal use only) <br /> (Check one ilem only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal"a only) OVERFILL PROTECTION EQUIPMENTS YEAR INSTALLED <br /> (Check ak that apply) ❑ 1. SPILL CONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BAUFLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGIE WALL TANK Cheok all that a I): IF DOUBLE WALL TANK OR TANK WITH BLADDER Chock one item only: <br /> ❑ 1, VISUAL(EXPOSED PORION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ e. VACOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ S. MANUALMONITORING <br /> ❑ 4. STATISTICALINVENTORYRECONCIUATION(SIR)• ❑ e, TANKTESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST ED(YWOD8Y1� ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> .//-{ -�- J albns ❑Yea No <br /> CUPAFORM(4/99) // -7-L,) l' Formerly SV4RC13 Form B <br />