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J UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) i Page to of t TYPE OF ACTION I. NEW PERMIT C]4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION [1 6. TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8. TANK REMOVED g 3. BUSINESS NAME (Same as FACIWTY NAME or DBA -Doi Business As) FACILITY ID: T] l 4J1. 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. agency'.) TANK ID # 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes ❑ No 434 2-10 If "Yes," complete one page for each companment. DATE INSTALLED 435• TANK`` CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS 437 (YEAR/MO)_ArftPgZ K -1 .?tea jn }Chid 438. ADDITIONAL DESCRIPTION (For local use only) II. TANK: CONTENTS TAIJK USE 439• 440, PETROLEUM TYPE I. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Irchecked, complete Petroleum Type) ❑ lb. PREMIUM UNLEADED "X• DIESEL [16. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: 442. ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Ino.-mory page) 441. CAS# (Rom Hazardous Materials Inventory page ) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LIIJER ❑ 95. UNKNOWN 2. DOUBLE WALL ❑ 4. SINGLE WALL 1N A VAULT ❑ 99. OTHER 444. TANK MATERIAL -primary tank I. BARE STEEL 3. FIBERGLASS /PLASTIC ❑ 5. CONCRETE 95. UNKNOWN ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: (Check one item only) [12. STAINLESS STEEL C14. STEEL CLAD W(FIBERGLASS REINFORCED PLASTIC FRP W/100% METHANOL TANK MATERIAL -secondary tank C]1. BARE STEEL 3. FIBERGLASS/ PLASTIC ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 95. UNKNOWN 4a5. ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑ 99. OTHER (Check one item only) REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL S. CONCRETE TANK INTERIOR LINING C11. RUBBER LINED ❑ 3. EPDXY LINING LJ5. 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 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN ecus. DATE INSTALL 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER If A licable ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. O ERF111 PROTECT19N EQUIPMENT: YEAR INSTALLED 452. 1. ALARM (0 ❑ 3. FILL TUBE SHUT OFF VALVE 1. SPILL CONTAINMENT BALL FLOAT ❑ 4. EXEMPT (Check all that apply)13*. 2DROP TUBE . STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) 45a. 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ 1. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ I. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING 1714. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR)+ BIENNIAL TANK TESTING El 99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE I.'N PLACE INERT MATERIAL? 457. DATE LAST USED (YR/MO/DAY) 455' Q ESTIMATED QUANTITY OF SUBSTANCE REMAINING�� ESTIMATED YC5 ❑ No _gallons UPCF hwfwrc-b (1/99) - 1/4 http://www.uiiidocs.org Rev. 02/16/00