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NEED PROGRAM CONSOLIDATED FOPV TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 9 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT OW(11 EA f!HANL&E ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specifyreason) ❑ 8.TANK REMOVED BUSINESS NAME(same as FAciury NAME or DBA-Doing BusinessAs) 3. FACILITY ID: 1 ON I�tCLL FFT- RI `d !o LOCATION WITHIN SITE(optional) T 431. L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local a ency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK El Yes ED No 434. XIf"Yes,"complete one page for each compartment DATE INSTALLED 43$ TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO)v2 OO /& / 0) 000 ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440, ® 1. MOTOR VEHICLE FUEL ❑1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (if checked,complete Petroleum Type) 9 lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventorypage) 441. CAS#(from Hazardous Materials inventory page} 442. ❑ 4. HAZARDOUS WASTE 1 Used Oil) ' A'50 L` ^ 1 ❑ 95.UNKNOWN IM TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL C1 3. SINGLE WALL WITH EXTERIOR 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-primary tank 1. BARE STEEL Ll 3. FIBERGLASS/PLASTIC L3 5. CONCRETE 95.UNKNOWN 444. (heck one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FFIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank 13 1. BARE STEEL U 3. FIBERGLASS/PLASTIC u 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING LJ 5.GLASS LINING D 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LRIING ❑6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION I.MANUFACTURED CATHODIC El 3.FIBERGLASS REINFORCED PLASTIC E3 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 45o. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE_ ❑2.DROP TUBE ❑2.BALL FLOAT_❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION A description of the monitoring program shall be submittal to the local agency. IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 45`1• (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.M4NUAL TANK GAUGING(MIG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATO) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S rTANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER .TANK CLOSURE PT90!APERMANENT CLOSURE IN PLACE ESTIMATE ,P,,AIE LAST D(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAININGTANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes 0 No