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Owner Name (from Section 1) Location (fro m.Sectyorrll) Page No. of Pages <br />VI. DESCRIPTION OF UNDERGROUND <br />STORAGE TANKS <br />(Complete for <br />each tank at this location.) <br />Tank Identification No. (e.g., ABC-123), or <br />Tank No. <br />Tank No. <br />Tank No. <br />Tank No. <br />Tank No. <br />Arbitrarily Assigned Sequential Number (e.g., 1,2,3 ... ) <br />1. Status of Tank Currently in Use <br />(Mario all that apply E) <br />Temporarily Out of Use <br />Permanently Out of Use <br />Brought into Use after 5/8/86 <br />0 <br />0 <br />0 <br />2. Estimated Age ears <br />3. Estimated Total Capacity Gallons <br />4. Material of Construction Steel <br />0 <br />0 <br />0 <br />0 <br />(Mario one E) Concrete <br />0 <br />0 <br />0 <br />0 <br />Fiberglass Reinforced Plastic <br />0 <br />0 <br />0 <br />Unknown <br />0 <br />0 <br />0 <br />0 <br />Other, Please Specify <br />5. Internal Protection Cathodic Protection <br />(Mario all that apply ®) <br />✓ <br />4 <br />Ilnterior Lining (e.g., epoxy resins) <br />0 <br />0 <br />0 <br />0 <br />None <br />0 <br />0 <br />0 <br />0 <br />0 <br />Unknown <br />0 <br />0 <br />0 <br />0 <br />0 <br />Other, Please Specify <br />6. External Protection Cathodic Protection <br />(Mario all that apply E) <br />0 <br />0 <br />0 <br />0 <br />0 <br />painted (e.g., asphaltic) <br />0 <br />0 <br />0 <br />0 <br />0 <br />Fiberglass Reinforced Plastic Coated <br />0 <br />0 <br />0 <br />0 <br />None <br />0 <br />0 <br />0 <br />0 <br />0 <br />Unknown <br />0 <br />0 <br />0 <br />0 <br />0 <br />Other, Please Specify <br />7. Piping Bare Steel <br />(Mar* all that apply E) <br />0 <br />0 <br />0 <br />0 <br />0 <br />Galvanized Steel <br />0 <br />0 <br />0 <br />0 <br />0 <br />Fiberglass Reinforced Plastic <br />0 <br />0 <br />0 <br />0 <br />0 <br />Cathodically Protected <br />0 <br />0 <br />0 <br />0 <br />0 <br />Unknown <br />0 <br />0 <br />0 <br />0 <br />0 <br />Other, Please Specify <br />8. Substance Currently or Last Stored a. Empty <br />in Greatest Ouantity by Volume <br />0 <br />0 <br />0 <br />0 <br />(Mar* all that apply0) b. Petroleum <br />Diesel <br />0 <br />0 <br />0 <br />0 <br />0 <br />Kerosene <br />0 <br />0 <br />0 <br />0 <br />0 <br />Gasoline (including alcohol blends) <br />Used Oil <br />0 <br />0 <br />0 <br />0 <br />0 <br />Other, Please Specify <br />0 <br />0 <br />0 <br />0 <br />c. Hazardous Substance <br />Please Indicate Name of Principal CERCLA Substance <br />OR <br />Chemical Abstract Service (CAS) No. <br />0 <br />0 <br />0 <br />0 <br />Mark box IN if tank stores a mixture of substances <br />d. Unknown <br />0 <br />0 <br />0 <br />9. Additional Information (for tanks permanently <br />taken out of service) <br />a. Estimated date last used (mo/yr) <br />BOTH REMO <br />ED ON DECE <br />BER 28, 19 <br />8 <br />b. Estimated quantity of substance remaining(gal.) <br />c. Mark box ® if tank was filled with inert material <br />(e.g., sand, concrete) <br />0 <br />0 <br />0 <br />0 <br />EPA Form 7530-1 (11-85) Reverse * U.S. Government Printing Office: 19."96.773 Page 2 <br />