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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE I (Two pages per tank) <br /> Page_of <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION 0 6 7.EMP�Y TANK LO UR9ITE a30 <br /> (Check...kem.ny) ❑ 3.RENEWAL PERMIT <br /> (Speciy...) (swirl reas.nl ❑ S.TANK REMOVED <br /> I. <br /> BUSINESS NAME(Same u FACILITY NAME.1 DBA-Doing Business M) 3. FACILfpYID: <br /> iJl. <br /> LOCATION WITHIN SITE op io-0 <br /> au 0ZU <br /> I.TANK DESCRIPTION <br /> (A scaled lo[plan With the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> No a3a. <br /> TANK ID# I. TANK MANUFACTURER COMPARTMENTALIZED TANK Yes <br /> If'Yez'romplcu orc page Por each companmem. <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS/ 456. NUMBER OF COMPARTMENTS 4A_ <br /> (YEAR/MO) zooz_ ZOe OQO _ Q'C onsZ <br /> V Ug. <br /> ADDITIONAL DESCRIPTION(For weal.eeomr) �/0��, <br /> '7 rc sok <br /> II.TANK CONTENTS <br /> 440. <br /> TANK USE 459. PETROLEUM TYPE <br /> V,I. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL <br /> (Ifchccka4.c.mpkre Pnmk:um Type) (j lb. PREMIUM UNLEADED - <br /> DIESEL [3 6. AVIATION GAS <br /> Cl 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADEUNLEADED C GASOHOL 01 OTHER:: u2 <br /> ❑ 7. CHEMICAL PRODUCT <br /> COMMON NAME(6.m Hamm...MmcHds ln.cmen page) 44I. CAS#(from Haeank.M...no.m.emon ') <br /> ❑ 4. HAZARDOUS WASTE <br /> (th.W.Ux40i0 <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑L SINGLE WALL ❑J. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH NTERNAL BLADDER SYSTEM 441 <br /> (Check one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> 2. DOUBLEWALL 4. SINGLE WALL IN A VAULT ❑99. OTHER 444 <br /> TANKMATERIAL-orlmary uM ❑1. BAREST <br /> FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.lNKNOWN <br /> (Check one acmo,10 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC(FRP) W11001/4 METHANOL <br /> TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 08. FRP COMPCIBLE W/100''/o METHANOL 095.UNK\OWN 445. <br /> (Check one item only) [12. STAINLESS STEEL[14. STEEL CLAD ( ❑WIFIBERGLASS <br /> 9, FCOATED STEEL JACKET ❑99.OTHER <br /> REINFORCED PLASTIC <br /> s. coucRETE <br /> OR COATING OR LINING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑O E2 fi.UNLNEDGLASS LINING ❑99.OTHER`� 446. DATE INSTALLED uy. <br /> fChak orc it..o ) <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC J.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER <br /> IfA lwitble) 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YE STALLED 450. TYPE 451. O�{ERFILLPROTECTTi NEQUIPMENT: YEAR INSTALLED 452. <br /> (Check all that apply) I.SPILL CONTAINMENT B I.ALARM is❑J.FILL <br /> EXEMPT BE SHUT OFF VALVE _ <br /> .DROP TUBE aB'2.BALL FLOAT ❑4.EXEMPT <br /> STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted to the local agency.) 4.4 <br /> IF SINGLE WALL TANK IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> (Check all that apply) (Check one item only) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(NITG) ❑LVISUAL(SNGLE WALL IN VAULT ONLY) <br /> C3 2.AUTOMATIC TANK GAUGING(ATG) ❑fi. � <br /> VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING <br /> [13.CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING [3 99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 4n. <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑ No <br /> Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-114 http:/Iwww.unidocs.org <br />