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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. GE,1OF INFORMATION [16.TEMPORARY TANK CLOSURE 430. (Chak one km Doty) ❑ 3.RENEWAL PERMITQ 6s) ()a✓ L ❑ 7.PERMANENTLY CLOSED ON SITE (Specifyreason) (Sise* -) ❑ S.TANK REMOVED BUSINESS AME(SameuFACa1TY NAMBmDBA-Doing Business Aa) 3. FACII.ITY ID: 1. 4 ,ar7a �A L Me4C� 7yS LOCATION WITHIN SITE(opts o 431. I.TANK DESCRIPTION A scaled plot plaa withthe location.of the UST system Including buildings and landmarks shall be submitted to the local agent .) TANK ID# 432. TANK MANUFACTURER aaa COMPARTMENTALIZED TANK ❑Yes No 434. ` A(4 X01 sy vI Tet,s c H"Ym"cavylae om page fhn eaea compa.nc DATEINSTALLED 411 1 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) / ADDITIONAL DESCRIPTION(Fm Incas use only) 438. 11.TANK CONTENTS TAN USE 439. PETROLEUM TYPE aao. MOTOR VEHICLE FUEL ❑fa. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL Orchakcs wapkte PCookum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (awa Hasu&.Materials lnvadory page) 'BICAS#(bom Ha is Mataia hyentmypage) 442. ❑ 4. HAZARDOUS WASTE (Includes USW tho ❑ 95.UNKNOWN ILL TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WTI'li LX f[RIOR ❑5. SINGLE WALL WITH INTERNAI.131.4DDF.R SVSIHli 443. (Check one itemDuly) MEMBRANE LONER El 95, UNKNOWN [S2. DOUBLE WALL ❑4 INGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-pmnary tam ❑L BARE STEEL FIBERGLASS/PLASTIC ❑A CONCRETE ❑95.UNKNOWN 444. (LTeck ore nem miy) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [IS. FRP COMPATIBLE ❑99.OTHER: 7NFORCEDPLASTTC FRP W/100%METHANOL TANK MATERIAL-ucoadary talc ❑1. BARE STEEL . FIBERGLASS/PLASTIC ❑8. FEE COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check me item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. PRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING .E 1.RUBBER LINED ❑3FOXY LINING ❑5.GLASS LINING [195.UNKNOWN 446, DATF INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one Them only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 44E. DATE INSTALLED 419. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER (If Applicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452 (Check all Out apply) ❑L SPILL CONTAINMENT ❑1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE [12.DROP TUBE ❑2.BALL FLOAT _ ❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION _. (Adescrition of the monitoring mgmm shall,be submitted to the local agency.) IF SINGLE WALL TANK 453, IF DOUBLE WALL TANK OR TANK WITH BLADDER454. (Check all that apply) (Check one them only) F]L VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTC) E]11..VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATC) ❑6.VADOSE ZONE 1j2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION [IS.TANK TESTING (SIR)+BIENNIAL TANK TESTING [199. OTHER V.TANK CLOSURE INFORMATION/.PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457 cellons [IYes ❑ No UPCF hwfwm-b(I/99)-1/4 http://www.unidecs.org Rev.02/16/00