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i IFIED PROGRAM CONSOLIDATED FOK TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (twO 08963 Pal tank) Page _ of TYPE OF ACTION 0 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE (Chock ons,leen only) C3❑7.RENEWAL PERMIT 7. PERMANENTLY CLOSED ON SITE I Specty reason-for local use only) (Speay cnange-for local use only) ❑ a TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) FACILITY ID a _17 I1 LOCATION WITHIN SITEjOpnondq 471 1.TANK DESCRIPTION TANK 10 a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea 10 No T R U S C O I1-yes complete one page for earls co pane L DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 10-99 10,000 ADDITIONAL DESCRIPTION(For local use only) Ili II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ® 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑ S. JET FUEL (If marked.complete Petroleum Type) :K1 1D. PREMIUM UNLEADED ❑ 7. DIESEL ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ J. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS a(fmm Hazardous Materials Inventory,page) Used Od) 095 UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK �❑1 1. SINGLE WALL C13. SINGLE WALL WITH ❑ 5. SINGLE WALL NTH INTERNAL BLADDER SYSTEM (Check ona,tom only) yl,+ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL•primary tank '❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5 CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ? 4. STEEL CLAD W/FIBERGLASS ❑ B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secomary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1, RUBBER LINED C33. EPDXY LINING ❑ 5. GLASS LINING C395. UNKNOWN437 DATE INSTALLED OR COATING Cheek one demo ) ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING El .a. UNLINED 1:199. OTHER (For local use ) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC R 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION 1F APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Chock one dem ordy) ❑ 2. SACRIFICIAL ANODE I I (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check ail that apply) fR 1. SPILL CONTAINMENT SI ��--ss 1. ALARM �7. FILL TUBE SHUT OFF VALVE U9 2. DROP TUBE 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK Check ail that apply: IF DOUBLE WALL TANK OR TANK WITH BLADDER!Chock one,tem only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑�1. VISUAL(SINGLE WALLIN VAULT ONLY) 112. AUTOMATIC TANK GAUGING(ATG) ❑ 9. VADOSE ZONE yyM2. CONTINUOUS INTERSTITIAL MONITORING ❑ 7. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 7. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ a. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL) gallons ❑Vas ❑No •r; i � , CUPAFORM(4/99) Fomlerty SWRC8 Form 8