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D► w. N�, UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) of 1 Page 4 f TYPE OF ACTION I. NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8. TANK REMOVED BUSINESSNAME(SameasFACIW7YNAMEorDBA-Doing Business As) T3.FACILITY FFT 77- _TAC- 10 `CSE gLsx l 817 -21 LOCATION WITHIN SITE (Optional) 431. I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TAN,y # 432. TANK MANUFACTURERS 433. COMPARTMENTALIZED TANK Yes El No 434. 1n( Gg?IXE755, If "Yes." complete one page for each compartment. DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 1 � 6 'Aftx ADDITIONAL DESCRIPTION (For local use only) 438. II. TANK CONTENTS TOK USE 439• PETROLEUM TYPE 440. x I. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ifcheckedcomplete Petroleum Type) ❑ Ib. PREMIUM UNLEADED _X. DIESEL ❑6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMICAL PRODUCT 441. COMMON NAME (from Hazardous Materials Inv:ntory page) CAS# (from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑ 95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL -primary tank Lj 1. BARE STEEL 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE 95. UNKNOWN 444. (Check one item only) [12. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTIC FRP) W/100% METHANOL TANK MATERIAL - secondary tank [11. BARE STEEL 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPTIBLE W/100% METHANOL [195. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL [14. STEEL CLAD IV/FIBERGLASS ❑ 9. FRP NON-CORRODABLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING ❑ I. RUBBER LINED ❑ 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING [16. UNLINED [199. OTHER (Check one item only) OTHER CORROSION 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (If A licable) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451, 0 ERFILL PROTECTIQN EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) I. SPILL CONTAINMENT I. ALARM (0 ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 4. EXEMPT _ 2. DROP TUBE BALL FLOAT 31 3. 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 454. 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 [199. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING a56. TANK FILLED WITH INERT MATERIAL'. 457. _ gallons ❑ Yes ❑ No UPCF hwfwrc-b (1/99) -1/4 http://www.unidocs.org Rev. 02/16/00