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Qa <br /> UNIFIED PROGRAM CONSOLIDATED FORM I <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages peIm. <br /> Page_of <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430, <br /> 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Clerk one ficm.nlY) ❑ ❑ S.TANK REMOVED <br /> (spepiry mason) (spniryrecon) <br /> I. <br /> BUSINESS NAME(sme as FACILITY NAME or DBA-Doing Bmloess Aa) 3. FACILITY ID: <br /> 431. <br /> LOCATION WITHIN SITE Option.b <br /> 1+ i%DI.TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks ANK MANUFshallbe submitted� ED TANK to the local agencyYee No a4. <br /> TANK ID# 432. TACTURER <br /> I•Yen^inmplae oM vag=for each co��enmem. 2 <br /> DATE INSTALLED <br /> 435. TANK CAPACITY IN GALLONS s. NUMBER OF COMPARTMENTS 437, <br /> (YEARIMO) 00 z- 00, 000 - .cleLlions 7- - <br /> 43e. <br /> ADDITIONAL DESCRIPTION(For meat ,.-.nry) _ n <br /> 101a <br /> II.TANK CONTENTS <br /> 440. <br /> TANK USE 439. PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑k�rIa. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> ofckmked.complere Parokum Type) 9lb. PREMIUM UNLEADED Q3.DIESEL 06. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (nam Hanrdon Mamrala lnvenory page) <br /> 441. CAS#(from Haxalloua MatenaB lnvemory page) 44z. <br /> ❑ 4. HAZARDOUS WASTE <br /> (incbdn Ufe4 Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> 1. SMGLE WALL F33. SMGLE WALL WITH EXTERIOR ❑5. SMGLE WALL WITH INTERNAL BLADDER SYSTEM 441 <br /> TYPE OF TANK ❑ MEMBRANE LINER 095. UNKNOWN <br /> (Check one item only) <br /> 2. DOUBLE WALL 4. SMG <br /> LE WALL INAVAULT 99. OTHER <br /> TANK MATERIAL-primary vaak ❑1. BARE STEEL . FIBERGLASS/PLASTIC ❑5. CONCRETE <br /> 095.UNKNOWN 444_ <br /> lC'leck one Tens o.ly) [3 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC FRP W/1001%METHANOL <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC 08. FRPCOMPTIBLE W1100%METHANOL 95.UNKNOWN +45. <br /> (Check oro Item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON <br /> GATED STEEL <br /> ORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑ <br /> 5. CONCRETE x6s <br /> TANK INTERIOR LINING 2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNOO-AZ <br /> LINEDG ❑99.OTHNNER-oOWN 446. DATE INSTALLED 447. <br /> OR COATING ❑ <br /> Check ore item or <br /> OTHER CORROSION 1.MANUFACTURFA CATHODIC 4.IMPRES ESDCURAENTCED PLASTIC ❑ :OTHER WN 448. DATE INSTALL 44 <br /> PROTECTION PROTECTION ❑ <br /> IfA liable ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451, O`Y I.RFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. <br /> (Check all that apply) I.SPILL CONTAINMENT �1.ALARM _❑3.PLL TUBE SHUT OFF VALVE <br /> .DROP TUBE 2.BALL FLOAT OW❑4.EXEMPT <br /> .STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submi=1FA <br /> WALL TANK OR TAlocal agency.) NK WITH BLADDER 4%.IF SINGLE WALL TANK m only)(Check all that apply) S.MANUAL TANK GAUGING (SMGLE WALLIN VAULT ONLY)❑l. VISUAL(EXPOSED PORTION ONLY) ❑ UOUS INTERSTITIAL MOMTORMG❑2.AUTOMATIC TANK GAUGING(ATC) ❑6.VADOSE ZONE❑3.CONTINUOUS ATG ❑7.GROUNDWATERL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 457, <br /> YR/MO/DAY 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED( ) gallons []Yes ❑ No <br /> UPCF hwfwrc-b(1/99).114 <br /> http://www.unidoes.org Rev.02/16/00 <br />