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11/01/2001 11: 27 20995193 '' VILLAGE WEST MARTHA PAGE 04 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TAN <br /> %S,- <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> Ow.awes pt.amv <br /> Page <br /> TYPE OF ACTION d 1.NEW SITE PERMIT ❑ a AMENDED PERMIT [� } CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> lCnK�Oma nam OMyl I-•�I Q 7, PERMANENTLY CLOSED ON SIT@ <br /> 1_1].RFNEwAL,PERMIT (Spooky Mason-ror local VM onm ($pkscvyounpt-WWw Vit Ond') ❑ t. TANK REMOVED 430 <br /> BUSINESS NAME(Sam.As FACILITY NAME or DBA-Doing Business As) FACILITY IO 0 1 <br /> ( �- U <br /> LOICAtION WITHIN SITE { 1 <br /> 1 <br /> ffqq <br /> 1 TANK 10 a / /� TANK MANUFACTURER I.TANK OESCmenOx <br /> COMPARTMENTALIZED TANK ❑ yes 0 No <br /> I Vy <br /> If•Yt4V,Wmplala ona papa for each fumP■19nam, <br /> DATE IN TALL ) TANK CAPACITY I NUMBER OF COMPARTMENTS <br /> 17 I9°l � I.2 000 <br /> ADORI NAL DESCRIPTION(For local usa amyl <br /> B.TANK CONTENT$ <br /> TANK USE 432 PETROLEUM TYPE <br /> 1 'l MOTOR VEHICLE FUEL ❑to REGULAR UNLEAM0 ❑ 2 LME0 ❑ 5. JET FUEL <br /> If/wunrao.:00W ra pal pyun Type) <br /> I.Or1D PREMIUM UNLEADED ❑ 1, DIESEL ❑6. AVuTION FUEL <br /> ❑ 2 NON.FUEL PETROLEUM <br /> ❑ <br /> � cnEMIcALPRooNcr Ic MIpGRADE UNLEADED ❑ •. GASOHOL ❑99 Cly-ER❑ <br /> ❑ • NAZ.AROOUS WASTE(lnNuWs COMMON NAME(Imm HatalaOLA MAtAANs Jn .sc.y papa) CAS/ ry papa) <br /> (hom HAzamOUA AlahnalA InwMO <br /> s � <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1 SINGLE WALL ❑ J. 51NQLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADQER SYSTBM <br /> (CMCY Ona ntm Oruyi 2. DOURLE WALL EXTERIOR MEMBRANE LINEA [a 99. UNKNOWN <br /> O {. SINGLE WALL IN A VAULT <br /> ❑M. OTHER <br /> TANK MATERIAL-prtmAry lank Va I BARE STFEL <br /> Al Q 9 FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑05. UNKNOWN <br /> ic—dM Mwt 0Ny) ❑ 2 STAINLESS SYEEL ❑{, STEEL CLAD WIF)SERGLASS C1 ! FAP COMPATIBLE YJ1100%METHANOL ❑99. OTNER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-Nc .ry 4nk ❑ I--�1. BARE STEEL El3. FIBERGUSSI PLASTIC CI ! FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> Itnec�oro nam only) ❑ 2, STAINLESS STEEL ❑ {. STEEL CLAD WIFIBERGLASS ❑ 9 FRP NOWCORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> )0 COATED STEEL <br /> © " CONCRETE <br /> LI11��11 <br /> NK INTERIOR LINING ❑ 1 RUBBER LINED ❑ J. EPDXY LINING LJ 5 QLA55 LINING Q 9S. UNKNOWN437 DATE INSTALLED <br /> OR COAT)NG 0..1 <br /> ❑ <br /> (Cn•CM OM,am2. ALKYD LINING ❑ {. PHENOLIC LININf3 Lal O UNLINED Q 94. OTHER <br /> OM or klcAl uu <br /> piHERCOAROSION ❑ I MANUFACTUREDCAT14ONC ❑ 3. FIBEAGLASSREINFORCEOPLASTIC IQS. UNKNOWN {3{ pATEIN$TALLED <br /> PROrECTIQN IF APPUCABLH <br /> PROTECTION r <br /> fCRAcA On.it..orKyl ❑ {. IMPRESSED CURRENT tq 99, OTHER ! <br /> ❑ 2. SACRIF IOLAL ANppE ary L (Fof klcal uq only) <br /> SPI,L AND OVERFILL YEAR INSTALLED TYPE(FIv WA/use <br /> only) OVERFILL PROTECTION EQUIPMENTYEAR INSTALLED <br /> fcnvc.all ow apply) <br /> ® ) SPILL CONTAINMENT ❑ 1. ALARM 7. FILL TUBE SHUT OFF VALVE <br /> 2 DROP TUBE A.J 2. BALL FLOAT D {. EXEMPT <br /> 193, STRIKER PLATE <br /> • r '�'' i'rI' �!IV.'TANK La11KOETEGTIG '.a? T <br /> IF SINGLE WALL TANK h"Aa that a 11F DOUBta WALL TANK OR TANK WITH BLADDER C&tk ona Nam <br /> ❑ +. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2 AUTOMATIC TANK GANGING(ATG) ❑ 0, VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ D. CONTINUOUS ATG (D 7. GRQIJNOWATER ❑ S. MANUALMON(TORING <br /> ❑ a STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ 9, TANK TESTING <br /> BIENNIAL TANK TESTING ❑99 OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USEO(YRlMOIDAY) ESTIMATED 01.1ANTITY OF SUBSTANCE REMAININQ {]S TANK FILLED WITH INERT MATERIAL? <br /> __.__._ _.. _.__...._-__......_pAaanA ❑ ❑Na <br /> Yee <br /> CUPAFORM(4199) Formerty SVVRCB Form 3 <br />