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UPCF hwfwrc-b (1/99) - 1/4 http://www.unidocs.org Rev. 02/16/00 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page!k of l TYPE OF ACTION 1. NEW PERMIT F1 4. AMENDED PERMIT C]5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. ❑ 7. PERMANENTLY CLOSED ON SITE (Check one item only) ❑ 3. RENEWAL PERMIT (Specify reason) (Specify reason) ❑ 8. TANK REMOVED BU$INES$ NAME (Same as FACILITY NAME or DBA- Doing Business As) 3. FACILITY ID: 'TACX- to -foe -acK $ I I S 17 431. LOCATION WITHIN SITE (Optional) I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local a ency.) TANK ID # 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes ❑ No 434. X'E,XES If"Yes;' complete one page for each compartment. DATEINSTALLED 435. 'TANKCAPACITYIN GALLONS 436. NUMBER OF COMPARTMENTS 437 Z (YEAR/MO) �l� '�k-2-1000 �J 438. ADDITIONAL DESCRIPTION (For local use only) II. TANK CONTENTS T6NK USE 439_ PETROLEUM TYPE 440. " MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED [:12. LEADED ❑ 5. JET FUEL J'"l (Ifchecked.Complete Petroleum Type) 19Ib. PREMIUM UNLEADED [:13. DIESEL [-16. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ 1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: 442. ❑ 3. CHEMICAL PRODUCT 441. COMMON NAME (from Hazardous Materials Inv,:ntory page) CAS# (from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPEOF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL; EXTERIOR C15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LIIJER ❑ 95. UNKNOWN o %2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT E]99. OTHER TANK MATERIAL -primary tank 1. BARE STEEL 3. FIBERGLASS / PLASTIC C35. CONCRETE 95. UNKNOWN 444. item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE [199. OTHER: (Check one REINFORCED PLASTIC FRP) W/100% METHANOL 3. FIBERGLASS / PLASTIC ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 95. UNKNOWN 445. TANK MATERIAL -secondary tank [11. BARE STEEL ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODABLE JACKET ❑ 99. OTHER (Check one item only) REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN 446, DATE INSTALLED 447, ❑ 99. OTHER OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED (Check one item onl ) OTHER CORROSION ❑ I. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 44e. DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (If A licable) [12. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 'TYPE 451. O ERFiLL PROTECTIQN EQUIPMENT: YEAR INSTALLED 452. CONTAINMENT 1. ALARM (0 ❑ 3. FILL TUBE SHUT OFF VALVE 1. SPILL FLOAT ❑ 4. EXEMPT (Check all that apply)13. 2. DROP TUBE .BALL STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER as4. IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ I. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR)+ BIENNIAL TANK TESTING ❑99.OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457. _ gallons ❑ Yes ❑ No UPCF hwfwrc-b (1/99) - 1/4 http://www.unidocs.org Rev. 02/16/00