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UNIFIED PROGRAM CONSOLIDATED FORM (� <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 1 <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 436 <br /> (Chak nee hem hely) 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (spaify recon) (spaify reeahn) 8.TANK REMOVED <br /> BS ESS NAME .F CILRV NAMa ar neA-Poing Bueinass As) 3. FACR,fCY ID: 1 <br /> eJl, 4 s <br /> L ATION WITHIN SITE(Opti,,)S -/&C' . <br /> q-630L4 <br /> 431 <br /> 1.TAN DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 432. TANK MANUFACTURER 433. <br /> T/� COMPARTMENTALIZED TANK ❑Yes No 434. <br /> CTE <br /> V6 IfWee;'wmpineoa 0ege for eazh wnpenmem. <br /> CARINSTALLED 435. TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS 437 <br /> 0 (96 6-,4 <br /> ADDITION�AL/j ESC�ION(por locel ��/� �h ^� YAss <br /> IL TANK CONTENTS <br /> t�/yrn <br /> K USE 439. PETROLEUM TYPE 440 <br /> 1. MOTOR VEHICLE FUEL <br /> ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> 0fc ake4 I.Whee Pmmkem Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION AS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL 99.OTHER Lti D V <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(6om Ha mu MarenaE Inventory page) 441' CAS#(6om He .Mal Invemmy page) 442. <br /> ❑ 4. HAZARDOUS WASTE <br /> (I.ImeetheA0i0 <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL [33. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> (Check one item only) A MEMBRANE LINER 095. UNKNOWN <br /> 2. DOUBLE WALL Q . [199. <br /> FIBERGLASS/PLASTIC 05. CONCRETE [195.UNKNOWN dao. <br /> (Chat me hem only) ❑ . STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑W.OTHER: <br /> REINFORCED PLASTIC W/I00%METHANOL <br /> TANK MATERIAL-secondary teak ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W1100%METHANOL 1-195,UNKNOWN 445. <br /> (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FBERGLASS ❑9. FRP NON-CORRODABLE JACKET 99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING L RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING 115.UNKNO a46. DATE INSTALL" 447. <br /> OR COATING ❑2.ALKYD LINING [34.PHENOLIC LINING ❑6.UNLINED 99.OTHER �/. <br /> Cbeck one item mal `1D <br /> OTHER CORROSION Ll 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 95.UNKN 44a. DATE INSTA D 449. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT 99. <br /> If livable [12.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. <br /> (Check ell that apply) ❑1.SPILL CONTAINMENT I ❑I.ALARM ❑3.FILL TUBE SHUT OFF VALVE _ <br /> ❑2.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted to the local agency.) <br /> IF SINGLE WALL TANK 453- IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (Check aE that apply) (Check oar item only) <br /> ❑I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> [13.CONTINUOUS ATG ❑7.GROUND WATER ❑3.MANUAL MONITORING <br /> [14.STATISTICAL INVENTORY RECONCILIATION C1 S.TANK TESTIN <br /> (SIR)+BIENNIAL TANK TESTING99.OTHER <br /> V.TANK CLOSU ZLA ON/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAB"L USED(YR/MO/DAY) 455, F SUBSTANCE REMAINING 456, TANK FILLED WITH INERT ATERIAL? 457 <br /> ESTIMA QUANTITY O , <br /> 7 S (J gallons ❑Yes No <br /> UPCF hwhvm-b(1/99)-114 http://www.Unidoes.org Rev.02/16/00 <br />