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UNIFIED PROGRAM CONSOLIDATED FORM �fDtL TANKS 7 UNDERGROUND STORAGE TANKS - TANK PAGE 1 I (Two pages per tank) Page_of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chale one hem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Sp-iry roma) (apeciry auov) ❑ 8.TANK REMOVED BUSINESS NAME(Same,ae FACILITY NAME of DBA-Doing ea.M.NO 3. 1 FACILITY ID: I' LOCATION WITHIN Dptlon 1 SITE ab 431' T I.TANK DESCRIPTION (A sealed lot plan With the location of the UST system including buildings and landmarks shall be submitted m the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK)q,Yes NO 434, ITA osis r<s� X e��x eo If"Yea'"com,kn, M page fa each comnanment DATE INSTALLED 435. TANK CAPACITY IN GALLON 6. NUMBER OF COMPARTMENTS 37 (YEAR/MO) zoo Z ZU, 00 0 - a.l!Dns Z. ADDITIONAL DESCRIPTION(Fo,kite um only) 438_ 2 - II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 9 1. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED [12. LEADED ❑S. JET FUEL (Ifchaked,com,,lete petroleum Type) K Ib. PREMIUMUNLEADED 0 3.DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (fim.Havrdoua Mamrul.Inwmory Mc) 4d1CASM(6om H.,&ua Mattons,lnvcn[ory page) 402 ❑ 4. HAZARDOUS WASTE Omindev U.ed oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443_ (Check oce itemoNy) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL INA VAULT 99. OTHER TANKMATERIAL-privuryw�k 1. BARESTEEL . FIBERGLASS/PLASTIC 5. CONCRETE ❑95.UNKNOWN 4" (C k one nom only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100°.5 METHANOL TANK MATERIAL-secondary lank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100nk METHANOL ❑95.UNKNOWN us. (Check one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL 5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED [199.OTHER Check one item onl OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER If licable [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 1 TYPE 451. OYERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT KI.ALARM ❑3.FILL TUBE SHUT OFF VALVE .DROP TUBE 2.BALL FLOAT ❑4.EXEMPT .STRIKER PLATE IV.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 one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE W2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. F,STIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 httpd/www.unidocs.org Rev.02/16/00