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J UNIFIED PROGRAM CONSOLIDATED FORM U TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page A- of'l TYPE OF ACTION 1. 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 I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3. FACILITY ID: 'TAS- i 1S CSE fox $ -I l S 431. LOCATION WITHIN SITE (Optional) I. TANK TANK ID #432. TANK MANUFACTUR ,'2-.,A 1C1q?_KE7!5' DATE INSTALLED 435. TANK CAPACITY IN C (YEAR/MO) nn Wr -7 - M k'2-14000 ADDITIONAL DESCRIPTION (For local use only) II. TANK: CONTENTS T NK USE 439 PETROLEUM TYPE y�Q�( I. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED (Ifcheeked.complete Petroleum Type) ` lb. PREMIUM UNLEADED ❑3. DIESEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 3. CHEMICALPRODUCT COMMON NAME (Rom Hazardous Maier" nHmtorypage) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN narks shall be submitted to the local_agency.) COMPARTMENTALIZED TANK �] Yes lJ No 434. If "Yes;' complete one page for each compartment. NUMBER OF COMPARTMENTS 437 438. ❑ 5. JET FUEL [16. AVIATION GAS ❑ 99. OTHER: 41. CAS# (Rom Hazardous Materials Inventory page ) 440- If A licable) 1-12. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 'TYPE 451. O ERFILL PROTECTIpN EQUIPMENT: YEAR INSTALLED 452. (Check all that apply)113. I. SPILL CONTAINMENT 1. ALARM (0 ❑ 3. FILL TUBE SHUT OFF VALVE _, .DROPTUBE BALL FLOAT ❑ 4. EXEMPT STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted. to the local agency.) 454 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 1. VISUAL (EXPOSED PORTION ONLY) C32. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING E]3. CONTINUOUS ATG [37. 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 456. 451 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING TANK FILLED WITH INERT MATERIAL ESTIMATED DATE LAST USED (YR/MOIDAY) ❑ Yes ❑ No _gallons Rev. 02/16/00 UPCF hwfwrc-b (1/99) - 1/4 http://wwNy.uiii(locs.org 111. TANK CONS"1'RUU LIUIN 5. SINGLE ALL WITH INTERNAL BLADDER SYSTEM 443. I. SINGLE WALL [13. SINGLE WALL `NITH EXTERIOR C]W C]1. TYPE TANKne LII4ER ❑ 95. UNKNOWN o item only) (Check o 2. DOUBLE WALL 4. SINGLE WALL 1N A VAULT ❑ 99. OTHER 444 5. CONCRETE U 95. UNKNOWN /PLASTIC TANK MATERIAL -primary tank I. BARE STEEL 3. FIBERGLASS/ ❑ 4. STEEL CLAD W'FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: (Check one item only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC FRP W/100% METHANOL COMPTIBLE W/100% METHANOL ❑ 95. UNKNOWN 445. TANK MATERIAL- secondary tank ❑ I. BARE STEEL 3. FIBERGLASS /PLASTIC Li8. FRP ❑ W/FIBERGLASS ❑ 9. FRP NON-CORRODABLE JACKET 99.OTHER (Check one item only) ❑ 2. STAINLESS STEEL [14. STEEL CLAD REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL 5. CONCRETE I. RUBBER LINED [-I 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN 446. ❑ 99. OTHER DATE INSTALLED 447 TANK INTERIOR LINING OR COATING El 2. ALKYD LINING [14. PHENOLIC LINING ❑ 6. UNLINED (Check one item on) 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC WN 448. DATE 1NSTALLE 449. OTHER CORROSION PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT [3 99. OTHER If A licable) 1-12. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 'TYPE 451. O ERFILL PROTECTIpN EQUIPMENT: YEAR INSTALLED 452. (Check all that apply)113. I. SPILL CONTAINMENT 1. ALARM (0 ❑ 3. FILL TUBE SHUT OFF VALVE _, .DROPTUBE BALL FLOAT ❑ 4. EXEMPT STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted. to the local agency.) 454 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 1. VISUAL (EXPOSED PORTION ONLY) C32. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING E]3. CONTINUOUS ATG [37. 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 456. 451 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING TANK FILLED WITH INERT MATERIAL ESTIMATED DATE LAST USED (YR/MOIDAY) ❑ Yes ❑ No _gallons Rev. 02/16/00 UPCF hwfwrc-b (1/99) - 1/4 http://wwNy.uiii(locs.org