|
-07-03
<br />TYrE OF ACTION
<br />((-h_--k one sem only)
<br />12:24P More for Less 7
<br />0
<br />209 832 8078
<br />03
<br />UNIFIED PROGRAM CONSOLIDATED FORIIP 3/1, /D3 i
<br />UNDERGROUND STORAGE TANKS —TANK PAGE l (Iwo
<br />❑ ) NF.W SITP; 1'tlemff Q 4 ANtEKDGD PERMIT' ❑ 5 CIIANGL OF INFORMATION ❑ 6 YENIKiRARY SITE CLOSUKE
<br />[ 7 Pf.RMANFN'I LY CI OSED ON SITE
<br />�] 3 I(ENr-.WAI. PERMIT (Slxcify reaw„ - hn fncaf use ar>iY) lSpnnCY i11wn
<br />BUS 5S NAME ( r- CII ITN' NAMIL orDDA - Mol lluzinew A0 )
<br />FACILITY ID:
<br />LOCATION WITIILN SITE (opt,oh.ti)
<br />for tical ux only) ❑ A TANK RFMOVfD
<br />P_07
<br />'1'A!N KS
<br />pages per iank)
<br />r•kT „+ i
<br />4JO
<br />__R_I
<br />J11
<br />(- TANK UESGRIPT(ON (,1 scale,! pint plan with tfie location yrlhc IIST.rystem including buildings andIandtn:trkc shall be submincJ In the Ideal agency)
<br />IAiv{ANUI ACi'!•IRF.R 433 CO MPARTMENTALILL'D'IANK
<br />TANK Ill N 4)) NK Ycs [ No J1J
<br />�=f� Irw,.-,.ony,le,eamwRcf..cKh:nnquanea+.
<br />i71 TANK CAPACITY IN UALLONS 414 NUMBER OF CUMPARTMENT$ uJ
<br />DATE VISTA LLD (YRAR O) / v)
<br />AC)T)ITiU AL DG$CR IPTION (rur k-1 v,m artly)
<br />PROTECTION IF' APPLICAIILE ritorECTION ❑ 4 IMPRESSED CUR RMT
<br />- —
<br />IF k,u,1 vie oUY)
<br />flhekanehem vnly) 02 SACRIFICIAL ANODE
<br />$PILl.ANDOVERFILL YEARINSI'ALLF, 450 'TYI'E(kx.LoeonlYl 4St--QVERrILL1'RU'IECTR7NEQi71FMLNT:YEAKINSTAI.LFIN ��
<br />(Ch.vk.Int..,.PplY1 1 SPI(LCONTAINVILNT !G k ❑ I ALARM ❑) FILI.TIMESHUTUFF VALVF
<br />(, 2 UROP TUBE %W R2 PAlt. r1.OAT ❑ 4 EXEMPT
<br />3 STRIKER PLATL 19
<br />V. TAMC LEAK ()FTE CTION (A tkrc.flnt,,...r,tn moraori proYsar, ,k.0 Is.,.1 mnN w the tical aR<ncy f
<br />437JSJ
<br />IF SINGLE WM.T_TAVK((.'(k�k.n1(�awnily+
<br />IF DOUBLE WALL-1'ANKOR TANKWI'I-IIBLADDER
<br />(L'hak one item c•c--1y)
<br />❑ t VISUAL (L)(POcF.D PORTION ONLY) ❑ - MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL r$iXOl.r. WALL IN VAUL-1 UNLYj
<br />❑ 2 AUTOMATIC TANK GAUGING (ATC) ❑
<br />6 VADOSE ZONE 2 CCIIITINI:OUS INTEKSITI TAI. MONITORING
<br />❑ 3 CONTINUOUS ATG 117 GROUNDWATER ❑ 3 MANI[Al.MON ITUKINU
<br />❑ 4 STATISTICAL INVENTORY KLCUVCILIATION ❑ 8 TANK TES IING
<br />(SIR) iiLLSNNIAI. TANK TEt I'IVC: ❑ 99 OTIAL'K
<br />IV. TANK CLOSURE INFORIVIAT16N / PERMANENT CLOSURE IN 1'LACF.
<br />494 - Jc7
<br />455 ESI (MATED QUANTITY OF SI:RSTAVCF. REM! KING TANK FILLF,T) WIT!! INLK'T MAI ERIAI
<br />ESTIMATED DATE (AST ulw (YR/MO:DAY) Cl Yes 13 N1/
<br />gallons _
<br />Formerly SWRC.14 Form 13
<br />UPCF (12199 revised)
<br />11, TANK C:ONTENI'S
<br />•
<br />TANK IISE
<br />((') PFTRULLiIiM TYPE
<br />un
<br />MOTOR VBI IICLE FUEL ❑ In. REGULAR UVLEADEU ❑ 7,, I.GADLU,
<br />❑ S. )IIT FUEL
<br />(It nnrkeJ complo, P0.01aum IYpe)
<br />Ib PREMIUM UNLF,ADEU ❑ 3. r)1 FS E!.
<br />❑ 6 AVIATION FUEL
<br />E12. NUN -FUEL PF.TROLEUM ❑ la MIDGItADE UNLEADED ❑ 4. GAS01101_
<br />❑ 90, ot-ur.11
<br />u'
<br />❑J.CHEMICAL PR000C'I
<br />'
<br />CO.MMONNAML'(fr-"N Jous6Yxcnbinw�nmyr}tip)
<br />Jll CAS1FIfrom ll.v:...hn.>MnerWlslmento7 p;,Cat
<br />❑4. HAZARDOUS WASIT
<br />❑ 95. UNKZ;OwN(�lI-
<br />- -
<br />- 111_ TANK CONSTR11C•"17110\
<br />WALL ❑ 3. SINGLE WAI_L WITII _--
<br />❑ >. SYS 1(j(JC WALL W It INTERNAL IILAUUtK SY$TfM JJ.1
<br />TYPESINGIJC
<br />L•'X'1'EKIOI( MEMRRANE LINER
<br />[]!)5. UNKNOWN
<br />(('Im.k onr item an1Y1
<br />JA �. UOIJB►,F. WALL ❑ 4 Su. AL1' WALL IN VAULT
<br />❑ 99. O'1 HER -
<br />-KNOWN
<br />_
<br />TANKMATERIAI. I wcynnk ❑+ RARliSTEEL [�3. titltR<�I:A�C/PLASTIC
<br />5 CONCRETE ❑ v5 1,J
<br />i]-
<br />COMPTIIILE W/10fr'', htiiT11ANUL ❑ `P). OTI IER
<br />ium onlyl
<br />'. STAINLESS STEEL �y 4. S'rEEI. CI.AO W%1•IUFRGLASS
<br />❑ �� - !P1 -
<br />❑ 8 II(P
<br />Illmek one
<br />KEINFORCEr) PLASTIC (FKI')
<br />-
<br />-FIBERGLASS,.
<br />MATERIAL
<br />[] I. BAKE STITL .-0 3 PLASTIC
<br />_ Js9
<br />Q 5CONZKF,TE CI 9.5. (1NKNUWN
<br />Y ANK uCe,m4,ry,:„'k
<br />Tj 2. STAINLESS STEEL C)4. SrLIEL CLAD W1FIR1`RGI ASS
<br />❑ 8. FRP COMPTIDLE W,' 10U',4 METIIANOI. ❑ 9v- UI'H6K
<br />(Ch..k o.e nem only)
<br />pElwrORCEU PLASTIC irRp)
<br />❑ Iu. coxI ED STFEI.
<br />❑ s. CONCRFTr•.
<br />—
<br />❑ 3. LrOXV LINING S. GLASS LINT\(i ❑ `)S UNKNOWN 446 5ATF. INSTALI.Ei JJi
<br />r,CNK�{NTFRIOR I.IWNti
<br />El RIAMIE"R L(NF.r)
<br />OR COATING
<br />❑ 2 ALKYL) LININ(; 0 4 rHENOLIC LINING ❑ G UNI INFD
<br />❑ !)9 OTIIER (p„, („nluie only
<br />I(T�kone Brm Ont)t-
<br />...Jar DATE {NOTA LLF.I) .uo
<br />OTIIL'RCOKKOSION
<br />_
<br />❑IMANIIFACTCREDCATHODIC. ❑3 FIBERGLASS RErNrORCEUPLAStic C095 UNKNOWN
<br />r-199 OTHER
<br />PROTECTION IF' APPLICAIILE ritorECTION ❑ 4 IMPRESSED CUR RMT
<br />- —
<br />IF k,u,1 vie oUY)
<br />flhekanehem vnly) 02 SACRIFICIAL ANODE
<br />$PILl.ANDOVERFILL YEARINSI'ALLF, 450 'TYI'E(kx.LoeonlYl 4St--QVERrILL1'RU'IECTR7NEQi71FMLNT:YEAKINSTAI.LFIN ��
<br />(Ch.vk.Int..,.PplY1 1 SPI(LCONTAINVILNT !G k ❑ I ALARM ❑) FILI.TIMESHUTUFF VALVF
<br />(, 2 UROP TUBE %W R2 PAlt. r1.OAT ❑ 4 EXEMPT
<br />3 STRIKER PLATL 19
<br />V. TAMC LEAK ()FTE CTION (A tkrc.flnt,,...r,tn moraori proYsar, ,k.0 Is.,.1 mnN w the tical aR<ncy f
<br />437JSJ
<br />IF SINGLE WM.T_TAVK((.'(k�k.n1(�awnily+
<br />IF DOUBLE WALL-1'ANKOR TANKWI'I-IIBLADDER
<br />(L'hak one item c•c--1y)
<br />❑ t VISUAL (L)(POcF.D PORTION ONLY) ❑ - MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL r$iXOl.r. WALL IN VAUL-1 UNLYj
<br />❑ 2 AUTOMATIC TANK GAUGING (ATC) ❑
<br />6 VADOSE ZONE 2 CCIIITINI:OUS INTEKSITI TAI. MONITORING
<br />❑ 3 CONTINUOUS ATG 117 GROUNDWATER ❑ 3 MANI[Al.MON ITUKINU
<br />❑ 4 STATISTICAL INVENTORY KLCUVCILIATION ❑ 8 TANK TES IING
<br />(SIR) iiLLSNNIAI. TANK TEt I'IVC: ❑ 99 OTIAL'K
<br />IV. TANK CLOSURE INFORIVIAT16N / PERMANENT CLOSURE IN 1'LACF.
<br />494 - Jc7
<br />455 ESI (MATED QUANTITY OF SI:RSTAVCF. REM! KING TANK FILLF,T) WIT!! INLK'T MAI ERIAI
<br />ESTIMATED DATE (AST ulw (YR/MO:DAY) Cl Yes 13 N1/
<br />gallons _
<br />Formerly SWRC.14 Form 13
<br />UPCF (12199 revised)
<br />
|