3. Estimated total capacity (gallons) 4. Tank attributes all that apply) Asphalt-coated or bare steel ☐ ☐ ☐ ☐ ☐ Cathodically-protected steel (impressed current) ☐ ☐ ☐ ☐ ☐ Cathodically-protected steel (sacrificial anodes) ☐ ☐ ☐ ☐ ☐ Coated and cathodically-protected steel ☐ ☐ ☐ ☐ ☐ (impressed current) ☐ ☐ ☐ ☐ ☐ Coated and cathodically-protected steel ☐ ☐ ☐ ☐ ☐ (sacrificial anodes) Composite ☐ ☐ ☐ ☐ ☐ (steel clad with noncorrodible material) ☐ ☐ ☐ ☐ ☐ Concrete ☐ ☐ ☐ ☐ ☐ Fiberglass-reinforced plastic ☐ ☐ ☐ ☐ ☐ Noncorrodible tank jacket ☐ ☐ ☐ ☐ ☐ Lined interior ☐ ☐ ☐ ☐ ☐ Excavation liner ☐ ☐ ☐ ☐ ☐ Double-walled ☐ ☐ ☐ ☐ ☐ Manifolded ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Compartmentalized ☐ ☐ ☐ ☐ ☐ Field-constructed _________ _________ _________ _________ _________ Unknown Check box if tank has ever been repaired Other, specify here 5. Overfill protection installed (check all that apply) Automatic shutoff ☐ ☐ ☐ ☐ ☐ Flow restrictor ☐ ☐ ☐ ☐ ☐ High-level alarm ☐ ☐ ☐ ☐ ☐ Other, specify here _________ _________ _________ _________ _________ 6. Spill prevention installed Double-walled ☐ ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ ☐ 7. Piping attributes (check all that apply) Bare ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Galvanized steel ☐ ☐ ☐ ☐ ☐ Fiberglass-reinforced plastic ☐ ☐ ☐ ☐ ☐ Flexible plastic ☐ ☐ ☐ ☐ ☐ Copper Cathodically-protected (impressed current) Cathodically-protected (sacrificial anodes)
3. Estimated total capacity (gallons) 4. Tank attributes all that apply) Asphalt-coated or bare steel Cathodically-protected steel (impressed current) Cathodically-protected steel (sacrificial anodes) Coated and cathodically-protected steel (impressed current) Coated and cathodically-protected steel (sacrificial anodes) Composite (steel clad with noncorrodible material) Concrete Fiberglass-reinforced plastic Noncorrodible tank jacket Lined interior Excavation liner Double-walled Manifolded Compartmentalized Field-constructed Unknown Check box if tank has ever been repaired Other, specify here ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _________ 5. Overfill protection installed (check all that apply) Automatic shutoff Flow restrictor High-level alarm Other, specify here ☐ ☐ ☐ _________ ☐ ☐ ☐ _________ ☐ ☐ ☐ _________ ☐ ☐ ☐ _________ ☐ ☐ ☐ _________ 6. Spill prevention installed Double-walled Other ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 7. Piping attributes (check all that apply) Bare Galvanized steel Fiberglass-reinforced plastic Flexible plastic Copper Cathodically-protected (impressed current) Cathodically-protected (sacrificial anodes) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Underground%20Storage%20Tank%20Management%20Program.docx