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swe sot <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> f ==01�-OPageS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE <br /> 1 <br /> L Tx o ✓ <br /> Page of _ <br /> TYPE OF ACTION .NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5, CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one dem only) <br /> ❑S.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Speciry mason-for local use only) (Specify charge-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) FACILITY ID I ''. T 1 <br /> TIT <br /> S z 4%L c. F,4&=J <br /> LOCATION WITHIN SITE(Opaonag 431 <br /> e <br /> L TANK DESCRIPTION <br /> TANK 4D k TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes 2*10 <br /> /L ICILL-)� O If-Yes'.complete one page for each compartment <br /> DATE INSTALLED(Y'EARR1MO) TANK CAPACITY IN GALLONS !F' NUMBER OF COMPARTMENTS <br /> VA,) O v D <br /> ADDITIONAL DESCRIPTION(Fcrfocal use only) <br /> IL.TANK CONTENTS <br /> �,� TANK USE 432 PETROLEUM TYPE <br /> L'J 1, MOTOR VEHICLE FUEL Ella. REGULAR UNLEADED ❑ 2. LEADED ❑ 5_ JET FUEL <br /> (ll marked,complete Petroleum Type) <br /> ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRAOE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3.CHEMICAL PRODUCT .:: <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(fmm Hazafdous Mafadali inventory page) CAS s(from Hazardous Materials Inventory page) <br /> Used Oil) / <br /> 95 'N'NOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK <br /> �- SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNA!BLADDER SYSTEM <br /> (Cheek ane Rem only) Cl 2_ DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary!ark a+54 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2 STAINLESS STEEL ❑ 4 57EEL CLAD WIFIBERGLASS ❑ 8. FRP COMPA71BLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-seconaa J tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS!PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one Rem only) ❑ Z STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALI-ED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOY•4433 <br /> ❑ 2 ALKYD LINING ❑ 4- PHENOLIC LINING El6 UNLINED ❑99. OTHER <br /> on <br /> (Check o Rem only) <br /> (FOrlacal use eery) <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE {For fatal use <br /> SPILL AND OVERFILL YEAR INSTALLEO TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT-YEAR INSTALLED <br /> {Cneck all Thal apply) <br /> ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3 FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ s EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> iV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check alf that apply) IF DOUBLE WALL TANK OR TANK MTH BLADDER(Check one item only)' <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING{MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING{ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUCUS LN7ERS7ITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ <br /> A. STATISTICAL INVENTORY RECONCILIATION(SIR)t ❑ 0. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99, OTHER <br /> V.TANK CLOSURE INFORMATION l PERMANENT CLOSURE IN PLACE I <br /> ESTIMATED GATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED VATH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> CUPAFORrd(4199) Formerly SWIRC8 Form 8 <br />