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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5,CHAIN/GE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (peck we tem oNY) ❑ 3.RENEWAL PERMIT A/040Q�lUf/L ❑ 7.PERMANENTLY CLOSED ON SITE (SpeciNmawn) (Sleety remora) ❑ 8.TANK REMOVED 3. FACILITY im 1' BUSINE NAME(Smoem PACILITY NAME«DBA-Doing Business As) ti^ � a W_Z 10.4a I:: e4c LOCATION WITHIN SITE(00-1) 431. I.TANK DESCRIPTION .,scaled plot plartwith the location of the USE system including buildings and landmarks shall be submitted to the local agency.) TANK ID# ^ 432. TANK MANUFACTURER 433 76e - COMPARTMENTALIZED TANK Ll Y;; No 434. Tr (OS'A5 (KC� R•rex^covplemn«weer«eameomp�tmew DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 2/2 J7/P // -)Z7 ADDITIONAL DESCRIPTION(For I«al me oma) 438. lt.TANK CONTENTS TAN USE 439. PETROLEUM TYPE 440 1. MOTOR VEHICLE FUEL ❑Is REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL nfchekd.compine Petmkum Type) (y, PREMIUM UNLEADED 03. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCE COMMON NAME (amu Hazardous Mata blhvatm wge) 441' CAS#(amm Hazedom Mmeriela hrvmnay page) 442. ❑ 4. HAZARDOUS WASTE 0«awes Dad a0 ❑ 95.UNKNOWN _ III.TANK CONSTRUCTION TYPE OF TANK ❑1.SINGLE WALL ❑3. SINGLE WALL WITH EX rER10R ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check ase itemovly) �/ MEMBRANE LI11R El 9i. UNKNOWN [j}2. DOUBLE WALL 4 SINGLE WALL IN A VAULT [199. OTHER TANKMATSUI -primeyta 1. BARE STEEL . FIBERGLASS/PLASTIC ❑5. CONCRETE LI 95.UNKNOWN a4. (peck orae Item only) ❑2. STAINLESS STEEL (:14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: FORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL . FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED Ll 3.EPDXY LINING ❑5.GLASS LINING 0 95.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one hers only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER fApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE [12.DROP TUBE [12.BALL FLOAT ❑4.EXEMPT ❑3.STRIKER PLATE IV.-TANK LEAK DETECTION (A descriptionof the monitoring pmgmm shalt be submitted to the local agency.) . R SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check a0 that apply) (Check me item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DA G 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 1 TANK FILLED WITH INERT MATERIAL? 457 pllom ❑Yes ❑ No UPCIF hwfwm-b(1/99)-1/4 httpt//www.noidamorg Rev.02/16/00