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bo UNIFIED PROGRAM CONSOLIDATED FORM 7-4 l ) TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (tiro pages per tank) I Page of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT All, CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE I (Check one item only) A 1_ ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spey mason•for local use only) (Specdy change-for ocal use only) ❑ 8. TANK REMOVED 430 O 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY too LOCATION WITHIN SITE(Optionaq 431 fes\ � C LEtc 1.TANK DESCRIPTION TANK ID 0 TANK M NUFACTURER ECOMPARTMENTALIZED TANK 11 Yes No �� 45 � � �� It'Yea',complete one page for each com rtmant. DATE INSTALLED(YEAR/M0I TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(Forlocal use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE C1 5. JET FUEL 1. MOTOR VEHICLE FUEL ta REGULAR UNLEADED ❑ 2. LEADED marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL ❑ ❑ 2. NON-FUEL PETROLEUM El 1c. MIDGRADE UNLEADED ❑ 4. GASOHOL 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) CAS 0(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(includes Used Oil) 95 UNKNOWN - III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) t� DOUBLE WAIL '❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL•primary tank ❑ 1. BARE STEEL El3. FIBERGLASS I PLASTIC C35. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/1001,1e METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3 FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD W/FIBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1• RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED 99. OTHER (For local use on!) (Check one item onl) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER ❑ 4. IMPRESSED CURRENT (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE DROP TUBE �© ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV.'TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onty): IF SINGLE WALL TANK(Check all that a ): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) . ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. MANUAL MONITORING ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yea ❑No Formerly SWRCS Form B CUPAFORM(4/99)