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AdL <br /> low <br /> UNIFIED PROGRAM CONSOLIOATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 01 <br /> {two pages per tank) <br /> Pape yr <br /> TYPE OF ACTION NEW SITE PERMIT ❑ a.AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION) ❑ E. TEMPORARY SITE CLOSURE <br /> (Chock une dam onlyy A <br /> 0 7. PERMANENTLY CLOSED ON SITE <br /> ❑3 RENEWAL PERMfT (spac-yy isasvn-fvrMaef usa uNyl [Spaciy charpa-flor local we o,?y) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Sams as FACILITY NAME of DBA-Doing Buainass As) FACILITY ID 0 1 <br /> � . �. IF �� i <br /> LOCATION WITHIN SITE{Optry W 4311 1" <br /> L TANK DESCRIPTION <br /> TANK ID■ -y TANK MANUFACTURER <br /> f */ COMPARTMENTALIZED TANK ❑ Yes No <br /> ,Y\ 1f-Yes,CGmplete Onp page fw ea[h�Ampartmenf <br /> DATE INSTALLEO(YEAR+MO) TANK CAPACITY IN GIIkLLCNS NUMBER OF COMPARTMENTS <br /> a- IP? l5 coD <br /> ADOITIONAL DESCRIPTION(Ferlocal use enly) <br /> Ill.TANK CONTENTS <br /> TANA USE 432 PETROLEUM TYPE <br /> �1. MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> •{7/ rked,complsts PermleumType) ❑1h PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> 0 Z. NON-FUEL PETROLEUM ❑Ic MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99 OTHER <br /> ❑ 3 CHEM[CALPRODUCT <br /> ❑ 4. HAZARDOUS WASTE tlndudes COMMON NAME(from HaaardOus Maurtsra 1nhMary papa) CAS S(hom Naaardaus Ma tanals rnwntcrypags) <br /> usdd Om <br /> IN.TANK CONSTRUCTION <br /> TYPEOFTANK ���rrr❑rrr 7 SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WTH INTERNAL BLADDER SYSTEM <br /> (Check cm 40Monly) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER <br /> Cl 95. UNKNOWN <br /> ❑ 4. SINGLE WAU.IN A VAULT <br /> ❑99 OTHER <br /> TANK MATERIAL-primary rank ❑ 1 BARE STEEL I. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check Qm 40m only) ❑ Z. STAINLESS STEEL ❑4. STEEL CLAD VWFIBERGLASS 8. FRP COMPATIBLE W+1 CO%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC{FRP) X <br /> TANK MATERIAL-sscsndary unk ❑ RARESTEEL FIBERGLASS I PLASTIC FRP COMPATIBLE Wr100%METHANOL ❑95. UNKNOWN <br /> (Check one item onyy 132. STAINLESS STEEL 0 4.STEEL CLAD WIFIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 70. COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED 03. EPDXY LINING ❑ 5. GLASS LINING _❑95. UNKNOWT1433 DATE INSTALLED <br /> OR COATING <br /> fGrreck one Rom on+1 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING a UNLINED 99 OTHER <br /> (For 1pCar use <br /> OTHER CORROSION Cl I. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 DATE INSTALLED <br /> pRD7ECTIOHIFAPPLICA8LE PROTECTION ❑4. IMPRESSED CURRENT ❑99. OTHER/ft 1,�_ <br /> {ChsrX ow#°^I 0*) 0 2. SACRIFICIAL ANODE (For kxal use onry] <br /> SPILLAND OVERFILL YEAR INSTALLED TYPE(Fvrlocalvse w+tyy OVERFILL PROTECTION EpUIPMENT:YEAR INSTALLED <br /> (ChsGr go oral apply) ❑ I. SPILL CONTAINMENT <br /> ❑ 1. ALARM FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check aN that IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check cne+lem only). <br /> ❑ 7, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ Z. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ a. CONTINUOU,IS ATG ❑ 7_ GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ B. 7ANKTESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. OTHER <br /> V.TANK CLOSURE WFORMATION t PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE LAST USED(YRIMQDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> I� � galmhs <br /> ❑Yea Cl No <br /> CUPAFORM(4199) <br /> FOrmerty SWRC9 Farm 6 <br />