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UNIFIED PROGRAM CONSOLIDATED FORM t l Y r TANKS `/(: ;At q UNDERGROUND STORAGE TANKS- TANK PAGE i (Two pages per tank) Page_of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ b.TEMPORARY TANK CLOSURE 430. (Chock one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify renin) (9pocify rcuon) ❑ 8.TANK REMOVED BUSINESS NA (S.a FACILITY NAME or DRA-Dow,lawkinee Ar) ]. FACILITY ID: 1. ME roc LOCATION W INCb SITE(optiona) 431. fie"s Ir i r .a -A"Mu r Vii vie, 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�r�7#{ ` 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK El Yes No 4M. l 0/ D5,5�g - If"Yei,"wmplete one one for each compannnent. DATE INSTALLED 435: TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437, (YEAR/MO) zoo z 1 7,O/ 000 ADDITIONAL DESCRIPTION(For beg one only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 'K 1. MOTOR VEHICLE FUEL %Is. REGULAR UNLEADED [12. LEADED [15. JET FUEL pfchwlua,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL [3 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADEUNLEADED ❑4. GASOHOL 099.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (6om Hvzvdom Materv6lnvcmorypge) 401' CAS#(6om Hazardous Materials lnvenmry page) 443. ❑ 4. HAZARDOUS WASTE (Imludes Ured Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-mimnry tank 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. (Chock oro hcm only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 01. BARE STEEL FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check ore iwmonly) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING E3 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED 447, OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING [16.UNLINED ❑99.OTHER (Check oro item pnl OTHER CORROSION 0 1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfApplicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR IN LED 450. TYPE 45I. O FILLPROTECTIQN EQUIPMENT: YEARINSTALLED 452. (Check all flat apply) .SPILL CONTAINMENT O 1.ALARM Q ❑3.FILL TUBE SHUT OFF VALVE 2 DROP TUBE 1GC2.BALL FLOAT( [14.EXEMPT .STRIKER PLATE 6 W.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453' IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check oreitem only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) �❑I1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE R4.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG ❑7.GROUNDWATER [13.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.unidoes.org Rev.02/16/00