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AIFIED PROGRAMC-ONSOLIDATEDFOr".1 <br /> - - TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION 1 NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify Grange-for local use only) <br /> ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) FACILITY 10 e 1 <br /> LOCATION WITHIN SITE(Optional) 431 <br /> I.TANK DESCRIPTION <br /> TANK 10 lt� TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes ]E] No <br /> 61-2 D T R U S C 0 It-yes'.Complete one Page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 10-99 10, 000 <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ® 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ® 2. LEADED ❑ S. JET FUEL <br /> (If marked.complete Petroleum Type) -N 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS A(from Hazardous Materials Inventory page) <br /> Used Oil) <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ] 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-pnmary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ B. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING El1. RUBBER LINED ❑ 3. EPDXY LINING 1:15. GLASS LINING El95. UNKNOWN433 GATE INSTALLED <br /> OR COATING <br /> (Check one item only) ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED C199. OTHER <br /> (For local use only) <br /> OTHER CORROSION DATEINSTALLED <br /> PROTECTION IF APPLICABLE ❑ 1. MANUFACTURED CATHODIC R 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 <br /> PROTECTION <br /> El 4. IMPRESSED CURRENT C1 99. OTHER <br /> (Check one item only) <br /> ❑ 2. SACRIFICIAL ANODE (For local use only, <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use onW OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) <br /> 1. SPILL CONTAINMENT 1. ALARM <br /> ��77 V(3. FILL TUBE SHUT OFF VALVE <br /> tR 2. DROP TUBE 2. BALL FLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that appy): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> C] 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE X X 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> CUPAFORM(4/99) Formerty SV1/RCB Form B <br />