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•ner Name (from Section 1) Location (from Section 11) Page No. of Pages <br />• • OF -UNDERGROUND STORAGE -TANKS <br />,:nk Identification No. (e.g., ABC-123), or Tank No. <br />Tank No. <br />Tank No. <br />Tank No. <br />Tank No. <br />rbitrarily Assigned Sequential Number (e.g.,1,2,3... ) / , Fi & 0, / <br />a, asof`iNe <br />Status of Tank Currently in Use <br />® <br />0 <br />Q <br />Q <br />Q <br />Mark all that apply ®) Temporarily Out of Use <br />Q <br />Q <br />Q <br />Q <br />Q <br />Permanently Out of Use <br />Q <br />Q <br />Q <br />Q <br />Q <br />Brought into Use after 5/8/86 <br />Q <br />Q <br />Q <br />Q <br />Q <br />Estimated Age (Years) <br />-stimated Total Capacity (Gallons) <br />Viciterial of Construction Steel <br />..ark one ®) <br />Concrete <br />Q <br />Q <br />Q <br />Q <br />Q <br />Fiberglass Reinforced Plastic <br />Q <br />Q <br />Q <br />Unknown <br />Q <br />Q <br />Q <br />Other, Please Specify <br />-temal Protection Cathodic Protection <br />-'.,ark all that apply m I <br />Q <br />Q <br />Q <br />Q <br />Q <br />Interior Lining (e.g., epoxy resins) <br />Q <br />Q <br />Q <br />Q <br />Q <br />None <br />Q <br />Q <br />Q <br />Q <br />Q <br />Unknown <br />Q <br />Q <br />Q <br />Q <br />Other, Please Specify <br />xtemal Protection Cathodic Protection <br />Q <br />Q <br />Q <br />Q <br />Q <br />(Mark allthat apply ®) Painted (e.g., asphaltic) <br />Q <br />Q <br />Q <br />Q <br />Q <br />Fiberglass Reinforced Plastic Coated <br />Q <br />Q <br />Q <br />Q <br />Q <br />None <br />Q <br />Q <br />Q <br />Q <br />Q <br />Unknown <br />© <br />© <br />Q <br />Q <br />Q <br />Other, Please Specify <br />Ong Bare Steel <br />irk all all that apply®) <br />Q <br />Q <br />Q <br />Q <br />Q <br />Galvanized Steel <br />Q <br />Q <br />Q <br />Q <br />Q <br />Fiberglass Reinforced Plastic <br />Q <br />Q <br />Q <br />Q <br />Q <br />Cathodically Protected <br />Q <br />Q <br />Q <br />Q <br />Unknown - <br />Other, Please Specify <br />�. obstance Currently or Last Stored a. Empty <br />Greatest Quantity by Volume <br />Q <br />Q <br />Q <br />Q <br />Q <br />b. Petroleum <br />.?ark all that apply®) Diesel <br />Q <br />Q <br />Q <br />Q <br />Q <br />Kerosene <br />Q <br />Q <br />Q <br />Q <br />Q <br />Gasoline (including alcohol blends) <br />Q <br />© <br />Q <br />Q <br />Q <br />Used oil <br />Q <br />Q <br />Q <br />Q <br />Q <br />Other, Please Specify <br />r4at, Di <br />Q <br />Q <br />Q <br />Q <br />Q <br />c. Hazardous Substance <br />Please Indicate Name of Principal CERCLA Substance <br />OR <br />Chemical Abstract Service (CAS) No. <br />Q <br />Q <br />Q <br />Q <br />Q <br />Mark box ® if tank stores a mixture of substances <br />d. Unknown <br />Q <br />Q <br />Q <br />Q <br />Q <br />Additional Information (for tanks permanently <br />taken out of service) <br />a. Estimated date last used (mo/yr) <br />b. Estimated quantity of substance remaining (gal.) <br />c. Mark box IE if tank was filled with inert material <br />(e.g., sand, concrete) <br />Q <br />Q <br />Q <br />Q <br />Q <br />--'A Form 7530-1 (11-85) Reverse i+u.s. cowrnm•nt Printing office: 1986-49ea35 Pap 2 <br />