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► r o\1 IED PROGRAM CONSOLIDATED FOR0 TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two 0905 per tank) Page Z of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE \0 (Check a"item only; ❑ 7. PERMANENTLY CLOSED ON SITI(�) ❑3.RENEWAL PERMIT [Specify reason-for local use ONA (Specify avenge•for local use only) ❑ 8.TANK REMOVED 430 BUSINESS NAME(Sams es FACILITY NAME or DBA-Oomg Business As) FACILITY ID I 1 jgPP01%j ��v7ERPRISF (Nc- Da#. GMwrj m o LOCATION WITHIN SITE(Opbonell ,3,t2 3 s. GyRlsNSt��RvA1s T eJ¢. 5 1.TANK DESCRIPTION TANK 100 TANK MANUFACTURER COMPARTMENTALIZED TANK 13 Yes No �AN r Q It'Yoi.wnpkte one page W each 000Vsrtmant. _`�Ko NUMBER OF PARTMENTS DATE INSTALLED(YEA ) TANK CAPACITY IN GALLONS 167,75- \2- )000 ADDITIONAL DESCRiPT1014(For locsi use OW IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE �t. MOTOR VEHICLE FUEL ❑is. REGULAR UNLEADED ❑ 2 LEADED ❑ 5. JET FUEL (ir nyA<eLt complete PaUol"M Type) ❑I e. PREMIUM UNLEADED �3. DIESEL ❑ 0 AVATIO14FUEL ❑ 2 NON-FUEL PETROLEUM ❑Ic MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99. OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(aom 1443sfWus MaNrials inventory Pape) CAS I(from Hezamous Materials Imvntoy page) ❑ 4. HAZARDOUS WASTE(kWudes Used Dei 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ S. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Rem oniyJ 2 DOUBLE WALL EXTERIOR MEMBRANE LINER [395. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL 3 FIBERGLASS I PLASTIC ❑ S.CONCRETE ❑95. UNKNOWN (Check ane item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WfFIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL Clog OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-setwnday lank ❑ 1 BARE STEEL 3. FIBERGLASS 1 PLASTIC ❑ a. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one dam only) ❑ 2 STAINLESS STEEL ❑4. STEEL CLAD YWFLBERGLA55 ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LININGOATS INSTALLED OR COATING ❑ 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING El 95 UNKNOWN433 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LIN]Nr. Ix 8. UNLINED ❑99. OTHER For local use only) (Chock"4am J DATE INSTALLED OTHER C�tROSION ❑ 7 MANUFACTURED CATHODIC ❑ 9. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN y� 434 PROTECTION IF APPLICABLE PROTECTION ry - ❑ 4. IMPRESSED CVRRENT99. OTHER (For local use only) (Cf»ck one dem onyl ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For fecal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Chock as that apply) '{� 1 SPILL CONTAINMENT ❑ 1. ALARM 3. FILL TUBE SMUT OFF VALVE yJdAj,2. 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 IF SINGLE WALL TANK Check ea that APPOT ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ' ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ J. C.ONTIN000S ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTLCAL INVENTORY RECONCILIATION(SIR). ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION J PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRMO10AY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No Formerly SWRCS Form B I