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cy, - <br /> UNIFIED PROGRAM CONSOLIDATFzD FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> rc�/ <br /> (+u'D Pages Per tank) <br /> Page _ of <br /> TYPE OF ACTION .NEW S17E PERMIT ❑ 4.AMENDED PF. w 5 CHANGE OF INFORMATIONS ❑ S.TEMPORARY SITE CLOSURE ` <br /> fCheck Ort#ftm arty) + Cl 7 PERMANENTLY CLOSED ON SITE <br /> 113 RENEWAL PERMIT (gpa reason-/D We,use GnW (Spscifychanga-for Axel w/anly) ❑ g TANK REMOVED 43o <br /> 9USINES NAM�4me as FACILITY NAME or DBA-Doing Business As) FACILITY lD R 1, <br /> IFIAl <br /> LOCATION WITHIN SITE(0p1+DrW 43 <br /> �f o GT� •c. <br /> I.TANK DESCRIPTION <br /> TANK I0 s O TANK MAHUFACTU ER COMPARTMENTALIZED TANK [] Yas ❑ <br /> If'Yes',ComPlela one page for each wm097uhnr <br /> DATE INSTALL (Y EA RIMt Q, TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> —' , <br /> ADDITIONAL DESCRIPTION fror loea7 use aNy) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> I MOTOR VEHICLE FUEL ❑IA. REGULAR UNLEADED ❑ 2. LEADED ❑ 5 JET FUEL <br /> fN arbd,COO"(@ PdtmreUnT 7ypQ) <br /> ❑It,. PREMIUM UNLEADED )K�. DIESEL ❑8. AVIATION FUEL <br /> 112 NON-FUEL PETROLEUM ❑Ic MIDGRADE UNLEADED ❑ 4 GASOHOL ❑99 OTHER <br /> ❑ 3 CHEMICAL PRODUCT <br /> ❑ 4 HAYARDOUS WASTE(1nNudas COMMON NAME(!mm hfazan:Wus Alalartals lm,smwy page) CAS s(!mm Mazardqur AfalsAals jawntwypage) <br /> u,:a Ail! <br /> ML TANK CONSTRUCTION <br /> TYPEOF TANK 01. SINGLE WALL ❑ 3 SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) X2. DOUBLE WALL EXTERIOR ME ME BANE LINER ❑yg UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑49 OTHER <br /> TANK MATERIAL-p'lmary Unit ❑ I BARE STEEL 43. F18ERGLASSI PLASTIC ❑�S CONCRETE ©95 UNKNOWN <br /> lchack ono,ram only) ❑ 2- STAINLESS STEEL ❑4 STEEL CLAD WIBE.RGLASS FRP COMPATIBLE WIIGO%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) - 1 <br /> TANx MATERIAL•seeanoary tank ❑ 1 BARE$TEFL FIBERGLASS I PLASTIC ❑ e. FRP COMPATIBLE W1100%METHANOL ❑95 UNKNOWN <br /> (Chxk one,ram nnly7 ❑ 2. STA I NLESS STEEL ❑4. STEEL CLAD YWFI BERGLASS ❑e FRP NO N-COR RODI SLE JAC KET 1199. OTHER <br /> REINFORCED PLASTIC(FRP) ❑1D COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING <br /> ORCOATING ❑ I. RUBBER UNED El 3. EPDXY LINING 135. GLASS LINING ❑95-UNKNOWNa33 DATE INSTALLED <br /> OR COATING <br /> ICheGr one,ram am) ❑ 2.ALKYO LINING ❑ 4, PHENOLICUNING XB UNLINED ❑99. OTHER <br /> (Far kxaf use an ] <br /> OTHER CORROSION ❑ I MANUFACTURED CATHODIC ❑ 3- FIBERGLASS REINFORCED PLASTIC 1195 UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4 IMPRESSED CURRENT 1399 OTHER_m1wkp <br /> (Check am loam unls4 ❑ 2- SACRIFICIAL ANODE {For kxae use an+y) <br /> SPI LL AND OVERFILL YEAR INSTALLED TYPE(Fw kcal use only) OVERFILL PROTECTION EDUIPME NT YEAR INSTALLED <br /> (Chock as mat apply) ❑ I. SPILL CONTAINMENT <br /> E011 ARM FILL TUBE SHUTOFF VALVE <br /> 2. DROP TUBE LL FLOAT ❑ 4 EXEMPT <br /> ❑ 3 STRIKER PLATE 1 <br /> FV TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(CllB arr(her a iy). IF DOUBLE WALL TANK OR TANK WITH BLADDER IChack Grte dam ); <br /> ❑ I- VISUAL(EXPOSED PORTION ONLY) n ❑ 5 MANUAL TANK GAUGING(MTG) ❑ I. VISUAL(5;NGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) / 111 ❑ S. VADOSEIONE ❑2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑3. MANUAL MONITORING <br /> ❑A. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑59 OTHER <br /> V.TANK CLOSURE INFOR-MATION 1 PERMANENT CLOSURE IN PUKE <br /> ESTIMATED GATE LAST USED(YRIMC(OAY) ESTIMATED QUANTIFY OF SUBSTANCE REMAINING TANK;ILLED WI TH INERT MATERIAL? <br /> /V A gallons 435 <br /> ❑Yes ❑No <br /> CUIRAFORM(4199) Formerly SWRCS Fcrm B <br />