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UNIFIED PROGRAM CONSOLIDATED FORM 1 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION 15a 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE <br /> 430. <br /> 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Chcckoneaem4nly) ❑ ❑ g,TANK REMOVED <br /> (Specify mason) (53xcifyresmn) 1_ <br /> BUSINESS NAME(S.as FACILITY NAME.,DBA-Doing Business M) 3. FACILITY ID: <br /> Q 431. <br /> LOCATION WI HIN STPE(Options" Arayl vc/ <br /> L TANK DESCRIPTION <br /> (A scaled plot planwith the location of the UST system including buildings and;an OMPARTMEbe Bbmitted to the local agency <br /> MALIZEDTAINK ❑Yes) No 434. <br /> TANK IDH 432 TANK MANUFACTURER <br /> 3f"YeA"romplete one page We each conpanmem. <br /> 43s. TANK APACITY IN GALLONS a36 NUMBER OF COMPARTMENTS 437 <br /> DATEINSTALLED � <br /> (YEAR/MO) Z/VO2' o0o c,-(Ic>n 1 - <br /> 438. <br /> ADDITIONAL DESCKWI ION(Fol local nm only) <br /> II.TANK CONTENTS <br /> 440, <br /> TANK USE 439. PETROLEUM TYPE <br /> I. MOTOR VEHICLE FUEL la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> pmhakd,complete Pmrokum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER: <br /> 441. CASH(ft.Hawdous Materuls lnvcmory page) 142' <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(kamxavkona Mmembinvemney wge) <br /> ❑ 4. HAZARDOUS WASTE <br /> (InclWn uaed oi9 <br /> ❑ 95.UNKNOWN <br /> III-TANK CONSTRUCTION <br /> TYPE OFTANK ❑L SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM "3, <br /> (Checkone itemonly) MEMBRANELINER El 95. UNKNOWN <br /> 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT 99. OTHER 4a4 <br /> TANKMATERIAL-v^nm'S1a"k ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑S. CONCRETE 95.UNKNOWN <br /> (Check one acre only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC ERP W/IBO%METHANOL <br /> TANKMATERIAL-secondary tank ❑1. BARE STEEL FBERGLASS WIFIBEIC ❑S. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. <br /> (Check oro item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑90 F OANON-CORRODABLE IACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑ <br /> ❑5. CONCRETE <br /> OR OATINGOR LINING [12.IALKYD-LINING ❑4.PHENOLIC-MING [16.UNLINED ING 0 95.❑99.OUTH R WN 406. DATE INSTALLED a7. <br /> Check one 49, <br /> imm onl <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC 3.FIBERGLASS 4.IMPRESSED CURRENTCED PLASTIC ❑ .UNKNOWN 44g. DATEINSTALLED 4 <br /> PROTECTION PROTECTION ❑ <br /> If licable 2.SACRIFICIAL ANODEYEAR <br /> SPILL AND OVERFILL YEAR IN$ -LED 450. TYPE 451. O RFILL PROTECT! NEQUIPMENT:TUBE SHUT <br /> OFF VALVE <br /> asx. <br /> 7 IALAI(M � ❑3.FILL TUBESHUT OFE VALVE__ <br /> (Check all that apply) W.SPILL CONTAINMENT 1GC2.BALL FLOAT(„[14.EXEMPT <br /> 2 DROP TUBE ` P <br /> .STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted te._WALL TANK OR TANK WITH BLADDER 454. <br /> 451 <br /> IF SINGLE WALL TANK (Check one itemonly) <br /> (Check all that apply) 5.MANUAL TANK GAUGING(MTG) 5❑�,I1.VISUAL(SINGLE W ALL IN VAULT ONLY) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑ > ,CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE <br /> ❑3.CONTINUOUS ATG <br /> [17.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING C]99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 457. <br /> 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) gallons ❑Yes [3 No <br /> UPCF hwfwrc-b(1/99)-1/4 <br /> http://www.unidocs.org Rev.02/16/00 <br />