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%a. �/ n UNIFIED PROGRA TANKS CO CONSOLIDATED FORM A UNDERGROUND STORAGE TANKS -TANK PAGE 1 IDI ry (Two pages per tank) Page_of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 7430, (Cheek one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (specify reams) (Speeify moon) ❑ S.TANK REMOVED BUSINESS NAME Is.as FACILITY NAME or DBA-Doing Hwmess M) 3. FACILITY ID: I' LOCATION WITHIN SITE o,k4a0 431' QJlt4�- I.TANK DESCRIPTION (A scaled plot plan with the location of the UST stem includin buildingsand landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK IQ Yes No 434. As - If•'Ya;"compkwommekremhcompanment. in DATE INSTALLED 435 TANK CAPACITY IN GALLONS 4J6. NUMBER OF COMPARTMENTS 437. (YEAR/MO) ZUOZ ZU, 00 0 - ce. l ops Z ADDITIONAL DESCRIPTION(F.,kcal...b) 438. l7KS� -- �,OC�C>- cLA•�O II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 446 9 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED [IS. JET FUEL (Ifchccked.complete Petmk a,Type) dab. PREMIUM UNLEADED DIESEL 06. AVIATION GAS [12. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED 4. GASOHOL [199.OTHER: ❑ 442 3. CHEMICAL PRODUCT COMMON NAME (ft.H.z .Mam,ialalmemary page) 441' CAS#(6om H.mrdom Materula lnwmory page) [1 4. HAZARDOUS WASTE Oacludm Umd Din ❑ 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 ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL INA VAULT 99. OTHER TANK MATERIAL-prinury uNt 1. BARE STEEL . FIBERGLASS/PLASTIC ❑5. CONCRETE 095.UNKNOWN /44. (Check one nem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCEDPLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARESTEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS []9. FRP NON.CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED Lj 3.EPDXY LINING LI 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447, OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION U 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN a4g. DATE INSTALLED 449, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfA licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YE STALLED 450. TYPE 451. 1 O FILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) L SPILL CONTAINMENT 1.ALARM ojf ❑3.FILL TUBE SHUT OFF VALVE_ .DROP TUBEeB'2.BALL FLOAT Q02,0 4.EXEMPT STRIKER PLATE !�' TV.TANK LEAK DETECTION (A description of the monitoring program shall be sub mod 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) ❑5.MAN UAL TANK GAUGING(MIG) ❑1.VISUAL(SING LE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE V2.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TAN K TESTING 099.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? 4S7' gall.. ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00