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lon-01-03 12:24P More "For Less 7 209 832 8078 O P.07 <br />L11VIN'IED PROGRAM CO;VSUi.IUATF.D FORM <br />UNDERGROUND STORAGE TANKS — TANK PA� <br />/IWO vacs ver lank) <br />TYl'E OF ACTION ❑ 1 NEW SITZ: i'EKMiT ❑ 4 AM1(E'.NnFD PLItMIT ❑: S CIIANGL OF INFOKMATION ❑ b 1'EmK)RARV SITE CLOSUKE <br />❑ 7 Pr.RM.lt�t:N1ktf1ff"TSHEALTH <br />lCh..-L one aem only) -'-aJU <br />�j J RENEW AI. PLKM(T (specify rrarvo - Gn meal use only) l5mury.eas)n for local u only) E l It 7"ANK RFM S <br />FACiLFI'Y ID: <br />RI151 5J NAME. (same as f PITY NAMk or DDA . 11-V U4 -inrsu A•) J / <br />JLOCATION WITHIN SITE (up,wnaU <br />L TANK UESC'RIPTiON (.1 sc:dal Plot plan with the location oTthe LIST system including buildings and tattd")=rrks shaft be svbminul in dle heat ngencyJ <br />ANK Ill N <br />f}2 <br />TA Kiv1ANUfACPC1kF.R as) CUhIPNtTMF.NTALILL LANK Ycs { II? a)a <br />3�-ji a-0 �2n� G�Jc t � <br />Ir-Y.•r,..my)ktr one Parc f • e.:6'o.yta Enrol. <br />A"fE T'4- LLD (Y�nR/MU) <br />ais ANK CAPACITY IV UALLC)NS O7f' NiJMAFR OF CUMPARTMFNTS u1 <br />pyo <br />,Di)(T10 ALL SCRIPTU).f ttveku iN--kty) <br />II. TANK CONTENTS <br />—"' TANK USF 4.19 <br />ROLLUM TYPE <br />ssa <br />MOTOR VEIiICLE FUEL <br />In. REGULAR UNLEADED ❑ 7, LEADED, <br />❑ 5. JET FUEL <br />(Il nvktd cvmdo' P'uote, 1 I YPE) <br />{] Ih PREMIUM U.NLFADEU ❑ ). i)IASEI. <br />❑ G AVIATIOIR FULL <br />Ei 2. NUN -FUEL PF.TROI.EUM <br />(] 1,: MimmAUE UNIT-ADED ❑ 4. OASOTIOL <br />[3!),). otimlZ <br />11. <br />❑!. CHEMICAL PRODUCT <br />' <br />CO.MNfOXNAME ItnvnNwu.Wus htateritbl—� yl"V) <br />aal CASIFI[romll�.,r.k.,.>. Mau..is ln�entory Pnrc t <br />Q4. HA7.ARDOL'S WASTE <br />Q 5. CONCKF,TF. 09.S. . . UNKNUu445 <br />(Inrludee lF.ni (FO <br />❑VS. UNKNOW-). <br />, <br />- <br />- <br />lit. TANK CONSTRUCTION <br />(� I. <br />S71N(-,I r WALL ❑ 1. SINGLE WALL WITH --- <br />❑ >. $IN(i1.F. \FALL W JJH INTERNAL IILAUULK SYSTEM aJ.l <br />TYPE OFTA.VK <br />- i-xruuOR MFtAnRANG LINER <br />[]!)S. CNKNOWV <br />(Ch -k ax item only) <br />V UI T <br />r"199 O'IHEK <br />(Ch.ck.11 th.t apply) I'1 I SPiLL CONTAINMUNT ❑ 1 ALARM ❑ 1 FILL TIME SHUT UFF VALVF. <br />Z URQP TUBE <br />2 11A1.t. FLOAT ❑ 4 EXEMPT <br />��� <br />[}� l S'I'RIKFR PLATE- <br />( V, TANK LEAK i)FTF.CTION (A dtx•:Pte.. orthe tmreomyt p+ouaw rh.il I<..t.mvai to the oral,kr^Fr t <br />ayi iF DO iRLE WALL TANK OR TANK Wr1'11 BLADDER J5a <br />IF SIS IGLL•. W ALL TANK (Cl -k o110W y,(.Iri [Caeek om itc..+nayl <br />❑1 VISUAL (EkPO$F.DPORTION ONLY) ❑5MANUALTANK IjAUGING(MTG) 0 ViSUAL!$iXrl.rWALL IN VAL'LI ONLY) <br />❑ 2 AUTOMATIC TANK GAUGING (ATC) <br />6 VADOSE ZONE %2 C'OV TNI:OUS INTERSTITIAL- MONITORING <br />❑ 3 CONTINUOUS nT() ❑ <br />7 GROUNLAVATER ❑ ) MANUAL MONITORING <br />❑ 4 STATISTICAL IN'V rNTOR1' I{LC•UW.'ILIATIN ❑ 8 TANK TESTING - <br />(SIR) BLNNIAI. TANK TLti-IV(: ❑ 99 OTHER _,... <br />!Y. I'AI%K Cr.OSURE INFORNIATION ! PERMANEA`T CLUSVRE 11 1•I.ACF. <br />f56 fc7 <br />a55 �WIATFJ) QUANTITY OF SCRST�tNCti REMAIKiNC7"ANK tILLFI) Vi1T11INEKTMAIERIAIESTIMATED DATE LAST USED (YR/MO:DAY)D Yes 0 Na gallons _ ._ <br />Formerly SWRC'K Form B <br />UPCF (12/99 revised) <br />UOIJBI,F WAL1- <br />❑ 4 CIGNLJ- W ALL IN A - <br />-_ <br />TANK MATERIAL p.mtary tank ❑ I _BARN STEEL <br />[] 3. FititKG1,AS-C i Pt.ASTiC — <br />- <br />❑ $ CO\CRI:TL D7 o tr`:KNOWN ua <br />COMPTItlLE WllOrY`k, hT1iT11ANoL ❑ 9'), t)Tl IrR <br />1(-"itiKk one itr�*..,nlyl <br />. STAINLESS STF..F.1. 4. S`I"EEL CLAD Wim13I'RGLASS <br />❑ ' YM <br />❑ 8 tRP <br />REINFORCED PLASTIC (VKV <br />TANK MAT F.RML seconatary .=v'k ❑ :. HAKt $TCGL <br />p 7 FIDFRGLASS i YLAS'TR' <br />Q 5. CONCKF,TF. 09.S. . . UNKNUu445 <br />U2. STAINLE%SSTEEL ❑4. STL•'L-"LCLADW/FIRrRGLASS <br />08. tRPCOMPTIBLEW,'I(W/.;.lFTllAYOI. 099.O'I'MEK <br />(rh-.k.,.�aereonly) <br />RFINFORLED PLASTIC (FRP) <br />0 ID. coo ED STFF.i. <br />(] 5. C'ONCRFTF <br />_ <br />' <br />❑ 3. EPDXY LNISiG S. GLAcS LINIKG ❑ 95 U\KNOWN aa6 ()ATF INCTAIJ.t:U <br />TANICINTFRIOR LININti <br />❑ i RIMIAR LINF.r) <br />OK COATING <br />❑ 2 At-KYV LINING <br />0 4 PHENOLIC I.INi\G E]6 UNi r irn <br />❑ !)9 OTI IER <br />(F- h.cal use only) <br />ICreck one ilrm vnly)., <br />.. - -• <br />_a.le DATE 1N6r1v.LhD +,o - <br />OTIIL'K CUKKOSION <br />❑ I MANUVACTCRED CAI <br />HODIC ❑ J nk%LxGLASS RrrNFORCEU 1'LA511C a(9S UNKNOWN <br />PROT@(TION IPAYYLI+'ATILT <br />P1{O'rtCflOt1 <br />❑ 0IMPKLSSEUCURStRT <br />❑99 OTIII:R -. <br />IFv.k-l..xeorly) <br />(check one item vnly) <br />❑ 2 SACRIFICIAL ANODE <br />451 OIL 4TIliNFQI}IPMLNT:YEAKINSTALf.EO -7 <br />SPILT•ANDOYC•RFILL <br />YEARi�STALL�D <br />a$V IYI'('ll-1veonly) <br />OVERFILLI'1{ <br />(Ch.ck.11 th.t apply) I'1 I SPiLL CONTAINMUNT ❑ 1 ALARM ❑ 1 FILL TIME SHUT UFF VALVF. <br />Z URQP TUBE <br />2 11A1.t. FLOAT ❑ 4 EXEMPT <br />��� <br />[}� l S'I'RIKFR PLATE- <br />( V, TANK LEAK i)FTF.CTION (A dtx•:Pte.. orthe tmreomyt p+ouaw rh.il I<..t.mvai to the oral,kr^Fr t <br />ayi iF DO iRLE WALL TANK OR TANK Wr1'11 BLADDER J5a <br />IF SIS IGLL•. W ALL TANK (Cl -k o110W y,(.Iri [Caeek om itc..+nayl <br />❑1 VISUAL (EkPO$F.DPORTION ONLY) ❑5MANUALTANK IjAUGING(MTG) 0 ViSUAL!$iXrl.rWALL IN VAL'LI ONLY) <br />❑ 2 AUTOMATIC TANK GAUGING (ATC) <br />6 VADOSE ZONE %2 C'OV TNI:OUS INTERSTITIAL- MONITORING <br />❑ 3 CONTINUOUS nT() ❑ <br />7 GROUNLAVATER ❑ ) MANUAL MONITORING <br />❑ 4 STATISTICAL IN'V rNTOR1' I{LC•UW.'ILIATIN ❑ 8 TANK TESTING - <br />(SIR) BLNNIAI. TANK TLti-IV(: ❑ 99 OTHER _,... <br />!Y. I'AI%K Cr.OSURE INFORNIATION ! PERMANEA`T CLUSVRE 11 1•I.ACF. <br />f56 fc7 <br />a55 �WIATFJ) QUANTITY OF SCRST�tNCti REMAIKiNC7"ANK tILLFI) Vi1T11INEKTMAIERIAIESTIMATED DATE LAST USED (YR/MO:DAY)D Yes 0 Na gallons _ ._ <br />Formerly SWRC'K Form B <br />UPCF (12/99 revised) <br />