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­iFIED PROGRAM CONSOLIDATED F,-._M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> i <br />)[ (two pages per tank) <br />• Page of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) 13 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify reason-for focal use only) (Specify cnange-for local use only) <br /> ❑ 8. 'ANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 <br /> LOCATION WITHIN SITE(Optional) 431 <br /> I.TANK DESCRIPTION <br /> TANK ID# 0061TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes No <br /> 5� 1 Y i�Y C•C If"Yes'.mmotete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> (79Z q <br /> ADDITIONAL DESCRIPTION(rorlocal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (If marked,complete Petroleum Type) Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL 1199. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> El d. HAZARDOUS WASTE(includes <br /> COMMON NAME(from Hazardous Matenals Inventory page) CAS#(from Hazardous Materials Inventory page) <br /> i <br /> Used Oil) <br /> 95, UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE'NALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE'NALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-pnmary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS 1 PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNC`NN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LININGC11. RUBBER LINED C13. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 GATE INSTALLED <br /> OR COATING <br /> C32. ALKYD LINING C34. PHENOLIC LINING C16. UNLINED C199. OTHER <br /> (Check one item only) (Forlocal use only) <br /> OTHER CORROSION '11C3 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC C395. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (Forlocal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE IForlocal use orae) OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED <br /> (Check all that apply) 1. SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 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 apply): 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 WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VAOOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. 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 /> El Yes ) ❑No <br /> CUPAFORM(4/99) Formerly SWRCS Forth 8 <br />