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11/01/2001 11:27 20995193 ? VILLAGE WEST MAPTNA PAGE 06 <br /> F <br /> co <br /> D UNIFIED PROGRAM CONSOLIOATEO FORM <br /> TANK <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (+aro race, <br /> POP• of \ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 9. TEMPOAAAY SITE C1.0$IIRE <br /> (Che A ane A-aN),) <br /> ❑1.RENEWAL PERMIT O 7. PERMANENTLY CLOSED ON SITE <br /> (sPFdh.eaan.Ar keu u4e eewy) (Sprdfy CAe 1e-M)OGe pyyJ ❑ 1. TANK REMOVED 410 <br /> BUS)NESS NAME iSI-iI..FACILITY NAME a D6A-ONN Buskwu Aa) FACILITY 10 0 1 <br /> 00 1 111 <br /> L ION WITHIN SITE(00" 411 <br /> 1 <br /> L TANK DESGRIPT{ON <br /> A 1 AN MAN R <br /> T�D�ag8�5 i/ C COMPARTMINTAIIZEOTANK ❑ YA. �Ne <br /> 11 Yes"oumWHft a»par Rr upon aompMvft'A, <br /> A INSTALLED(YEAR/MO) TANK CAP L N NUMBER PA <br /> 12 5760 a <br /> AOOITK)KA DESCRIPTION(FabcN wee wwy) <br /> IL TANK CONTENTS <br /> TANK USE 417 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑is REGULAR UNLEADED 2- LEADED ❑ S. JET FUEL <br /> (Hm A'w.9,,W1ala X'ePPleum�) ❑the PREMIUM VNLEApEp 7. DIESEL ❑ 0, AVIATION FUEL <br /> NON-FUE <br /> ❑ 7.CHEMICAL PETROLEUM L]1c. MIOGRADE UNLEADED ❑ a. GA$ONOL []L0. OTHER <br /> �❑y 7,CHEMICAL PRODUCT <br /> HAZARDOUS WASTE(1 l CO••++M��MON NAME(lrwn Nueudou*U feneb lmanIn papal fj.$/jeym h'etalaoue AIa!♦dala fnNrw <br /> L)-d0M -V / aywuq <br /> 111,TANK CONSTRUCTION 4r 4 <br /> TYPE OF TANK <br /> ❑ t. SINGLE WALL ❑ 1. SINGLE WALL VaTN ❑ 3. SINGLE WALLµATH INTERNAL BLADDER SYSTEM <br /> (GnICA pne If11„OMyJ _, DOUBLE WALL EXTEAIOR MEM$RAN9 LINEA <br /> �96. ul4KNoW+4 <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> �-y <br /> ❑94. OTHER <br /> TANK MATERUL-MA+Ory len* 1 BRAE STEEL ❑ ]. FIRE ROIrSS!PlA$TIC 0 5. CONCRETE ❑98. UNKNOµM <br /> (CneeA are.rum oNy) ❑ q. STAINLESS STEEL ❑4. STEEL CLAQ W/FIaeRQLAS$ ❑ e. FRP COMPATIBLE W)100%METHANOL ❑10-OTrtER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-sowndwy tan* 41. bA a STEEL ❑ J, FIBERGLASS I PLASTIC ❑ 1. FRP COMPAT10LE V IM%METHANOL ❑98. UNKNOMM <br /> (CAOOA Ort kem Onry) ❑ 7 STAINLESS STEEL ❑ 4. STEEL CLAD YOPMERGLASS ❑ P NON�CORRCO10LE JACKET ❑M. OTHER <br /> REINFORCED PLASTIC VAP) TV, L5 <br /> Y <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING rr��I _ <br /> OR COATINQ ❑ Id AU68ER LINED lJ 3. EPDXY LINING ❑ 5. GLASS LINING ❑00. UNKNOWN433 OATE INSTALLED <br /> GnecA ane kem o <br /> ❑ 7. ALKYD LINING ❑ 4 PN£NOUC LINING 56 Q. UNLINED Q9D. OTHER <br /> Fa McTY/LH <br /> OTHER CORROSION DATE INSTALLED <br /> PROTECTION IF APPLICABLE ❑ 1. MANUFACTURED CAYHOdC ❑ ]. FIBEAOLAS9 REINFORCED PLASTIC 03. UNKNOVIN aaa <br /> PROTECTION ❑ 4. IMPRESSED CURRENT a�( <br /> (C4e*one Nem onlyl JL7,00.OTHER <br /> ❑ 2, $AGRIFICIAL ANODE <br /> COADaJIUM <br /> SPILL AND OVERFILL YEAR INSTALLER TYPE(Fpr lone!uee pNy) OVERFILL PROTECTION EQUIPMENT:TEAR INSTALLED <br /> (Ct-A as Iluf apply) <br /> 1. SPILL CONTAIHMCMT ❑ I.ALARM �I,3- FILL TUBE SHUT OFF VALVE <br /> Z. DROP TVBE __,__❑ ❑ EXEMPT 7. BALL FLOAT a. <br /> ]. STRIKER PLATE <br /> ,.ply;, , ,,` ..n�N�::���;�.c. v"a...ry\A -�.;. ._, .•� / <br /> IF SINGLE WALL TANK ON MOIO IF DOUBLE WALL TANK OR TANK MTN BLADDER XhKk aM Wm , <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ IL MANUAL TANK GAVOLNO(MTO) f❑�� 1. VISUAL($INOLZ WAU.IN VAULT ONLY) <br /> ❑ I. AUTOMATIC TANK GAU¢ING(ATO) ❑ 9. VADQ$E ZONE pm R. CQNTINUOUS INTERSTITIAL MONITORING. <br /> © J. CONTINUOUS ATO ❑ 7. GROUHOWATER ❑ 1. MANUAL MONITORING <br /> Q 4, STATISTICAL INVENTORY RECONCILIATION(SIR)• C] 1. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. OTHER <br /> V.TANK CL09URE INFORMATION I PERNAJNENY CL)OSURH IN PLACE <br /> ESTIMATED PATE LAST USEO(Y"O/OAY) Iff"MATEO QUANTITY OF bu"TANCC RlIMAINING 436 YANK FIILEb,MTN INERT MATERIAL? <br /> OOIWert ❑WA ❑No <br /> CUPAFORM(4199) <br /> Formerly SWRC9 Form R <br />