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03/0712005 16:17 2094663433 FIFTH FLOOR PAGE 10 <br /> LNWIE a PP.acR.AM C0?ti=S+DX.mA#TED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS—TANK PAGE x <br /> (two mas per tank) <br /> P.4c_of_ <br /> TYPE OF ACTCOi i L7 I NEw SITE raRm. w M a.AmEmrm PERMT Q 5 CHANGE OF INFO[tY4A.TION Q 6 TEMPORARY SITE CLOSURE <br /> (Cncckottitemanly) ] 7 PERMANENTLYCLOSEDON SITE <br /> 3 R'EWWALPERMIT (-Wfyrea5w-farlaratmronly) 8 TANRREMOVEO 4m <br /> BUSINESS•NAM$(6oe4.aeTACILOYNAbM rEm-DOWBnsiaessAsi FACIIIT"Y <br /> LOCATION RVITFIEN SITE(ctpapal 431 <br /> L TA]NX DESCRIMON (A scaled pilot pW with the Wain of the USTsystem including buBdiap and tandtl7aea shaF!_be submitted to the load a8cricy) <br /> TANK ED# 432 TANK MANUFACYVR$R 433 COMPARTMENTALIZED TANK 10 Yes © No 434 <br /> fmci"eompLf one pegs fm meh apnpanattak <br /> DATE INSTALLED O EAR 0) 435 TANK CAPACITY TN GALLONS 436 NWqER OF COMPARTMENTS air <br /> t( - 00 Q <br /> ADDITIONAL DESCP,IYTIt}N(Fnr 10a1 Ian add) 4n <br /> ll.TANX CONTENTS <br /> TANK USE 43$1 PMOLRM TYPE 440 <br /> IK L M4OTOR VE)fICLE FUEL 'Ill. REG'MAR UNLEADED Q a.LEADED E3 S. JET FUEL <br /> (Ifmmisdeamptereftm*1emnTypr) JO 1b. FR'E WUM UNLEADED ❑3.DIESEL 'CI 6.AVIATION FUEL <br /> D 2.NON-FUEL PETROLEUM ❑Ic. NUDGRADE UNLEADED ❑4.GASOHOL W.OTHER <br /> ❑3.C9 41CAL PRODUCT COl~+IATON TAME m av m4wosf T4nuzi*bvaeoy p 442 CAS#(fmm Bamrdws Motabb lnvemvy Dri'7SK) 40 <br /> D a. OAZARIpU$WASTE <br /> (Ineiarte Used iltt? <br /> CO 9s UNKNOWN <br /> EAI.TA,NIt CONMUCnON <br /> TYPE OF TANK I. SINGLE WALL tf 3.SINGLE WALL WITH E3 5.SINGLE WALL%TM WMRNAL BLADDER SYSTEM 443 <br /> (Chcak ow gm oily) M CTERIOR MEMBRANE LIKW E)95.UNKNOWN <br /> Dga DOUBLE WALL ❑d. SIGIILE WALL IM VAULT ❑9F.OTHER <br /> 'TANKMATERIAL-pduimytark Ij L BARE STEEL U 3. FIBERGLASS I PLASTIC 5.CONCRETE P9 45.UNKNOWN 444 <br /> tCtwckawilammlrl 0 2.STAINLESS STEL ©4. STEEL CLAD WMEERGLASS ❑B.FRrC b4PTISLE Wt1t7446 METHANOL Q 99:OTHER <br /> P.EINFORCED-PLASM(FRP) <br /> TANK MATSRIAL-acwnd7sy-.k Ll 1.BARESTEEL Lj 3.FIBERGLASS i ELASTIC 5_ CQNCPZFE 95. UNKNOWN ¢15 <br /> (t_'eeticgot immonly) ". C.l 2. STAINLESS STEEL Q 4. STEEL CLAD WMBERGLASS LIS. FRP COW7T1RU Wtt(045KMA'NOL ❑7?.OTHER. <br /> REINFORCED PLASTIC(FRP} Cf!4.BOATED stErm <br /> Q 5.CONCRETE <br /> TANK INTERIOR LINING U 1.RUBBER LINED U 3.E'O:CY LINHNO 0 5,GLASS LINING 95.UNKNOWN 446 DATEINSTALLED ,4447 <br /> (}R COATING 132 ALKYD LIN NG ❑4 PHENOLIC L04ING D 6 UNLINED ❑99 OTHER 12' y <br /> (Chalcone itrnaaotY) (Fot14g1 ntwordY) <br /> OTHER CORROSION Q I MANUFACTURED CATHODIC Q 3 FIB€RGL.ASS R>r WORCEDFLASTIC Q PS C)NKNOWN ' DATE INSTALLEiD p449 <br /> PROTECTION IF APPLICABLE PROTECTION C3 4 IMPRESSED'(,A(R;pNT Q 99 Ormm f h� <br /> (Ch Wkk mm itam only) - Q 2 SACRIFICIAL ANODE (Fer Ios al ndc or$7'7 <br /> SPILL AND Ol7FRF T YEAR IC(STALLED 421 TYPE notal ohe an17) 4` OVERFILL PR{I MCSION SgUIPMENT.YSAR INSTALLED 452 <br /> (Chcckalldratamply) I SPILL CONTAINMENT ❑I ALARM A3 FILL TUBE SHAT OFF 1•ALVs <br /> 2 rw"TUBE ❑2 BALL FLOAT ❑4 E UMPT <br /> 3 STRIKER MATE <br /> W.TANK LEAK DETECTION(n dompria oftit vw*wOgar*0.nsmli'tre wbMimed to dm iml aggg7•) <br /> IFSDIGLEWALL TANK(Chwknitthatapply) 40 IFDOUSLEWALL TANK O"TANK WIIHBLADDER 454 <br /> (Chmk owdaom$y)' <br /> (]t VISUAL(EXPOSED PORTION ONLY) Q 5 MANUAL TANK QAu(;iNf.(MTG) ❑(VISUAL(mN(l-r,WALL IN VAULT ONLY) <br /> AUTOMATIC TANK GAMING{ATO) ❑6VADOSEZONE �2CON71KUOUSINTERSTMALMONITORING <br /> b3 CGNTIN'Ut1[IS Aw ❑7 GROUNDWATER ©3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION C]8 TANK TESTING <br /> (SIR)BIRKNIAL TANK TESTING E1 99 OTHER <br /> PC TW.TANK CLOSURE[IORNLAXION/FERNIANE 4t CLOSURE IN)*LACE <br /> ESTIMATED DATE LAST USED(YRIMO/DA'Y) Ass ESTIMATED QUANTITY OF SUMTANCE REMATt WO 4M TANK FILLED 1AgTH PORT MATERIAL? 451 <br /> -► gSllons ©Yev :WTO <br /> upcF(12/99 revised) 10 Formorly SWft.CB Form B <br />