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UNIFIED PROGRAM CONSOLIDATED FORM ►�)/ TANKS 1(� UNDERGROUND STORAGE TANKS -TANK PAGE 1 W'1 (Two ry� TP(V51 f) Page_of_ TYPE OF ACTION NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (One,mm item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Speeify'amem) (8peeify muov) ❑ 8.TANK REMOVED BUSINESS NAME(seme.r FACBITY MmDIA-WinH.m.Aj 3. 1 FACILITY ID: 1. C 4 C �z I d 4 a 010 S l 3 LOCATION IN SITE(opnemll431. I.TANK DESCRIPTION (A scaled plot plan with the location of the LIST system including buildings and landmarks shall he submitted to the local a enc J TANK ID N 432. TANK M'ANUFA�RER 433. COMPARTMENTALIZED TANK Yes No 434. (// If"Ves;'wmvleee me,page for melt weptee new. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) U E_^/ D� a7. ADDITIONAL DESCRIPTION(For leen mm may) ( 438. 11.TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED [IS. JET FUEL (lfs 1mLwnplem Petmlm en Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (apm Nasardom Maeuiils invenarypage) 441' CASK(6nm Hnardom MeemiW mamry p4gm) 442. ❑ 4. HAZARDOUS WASTE gaelude Used Oi0 5.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check mm iremody) MEMBRANE LINER El 95. UNKNOWN ❑ . DOUBLE WALL 4. SINGLE WALL IN A VAULT Cl 99. OTHER TANK MATERIAL-primus mn BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444 (p k one imm anly) ❑Z STAINLESS STEEL Cl 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W1100%METHANOL TANK MATERIAL-secondaey tank 1. BARE STEEL 3. FIBERGLAS 9lPLASTIC 8. FRP COMPTIBLE W1100%METHANOL.W93.UNKNOWN 445. (Check one imm only) 02. STAINLESS STEEL [I 4. STEEL CLAD W/FIBERGLASS ❑9. FRPNON-CORRODA13LE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING KNOWN 446. DATE INS T ED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER L , Check mm imm onlC/e V OTHER CORROSION ❑L MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 5.UNKNOWN 448. DATE INSTALLED u9. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER ITApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 1 TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINST 452. (Check all that apply) ❑1.SPILL CONTAINMENTI ❑1.ALARM [13.FILL TUBE SHAT ALVE ❑2.DROP TUBE �/ // ❑2.BALL FLOAT_ ❑4.EXEMPT' 3.STRIKER PLATE /�' IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the Imal agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454, rthat apply) (Check one item only) SUA (EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) [11.VISUAL(SINGLE WALL IN VAULT ONLY) AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE(. TUSED(YR/MO/DAY) 455, ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILI,7; H ERTMATERIAL7 452. I�//�_�/) 0 sallons ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidoc&org Rev.02/16/00