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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS V ,0 <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Two pages per tank) <br /> Page_of <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT5. QLD E OFd�+1 �RMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (ChNc ate Tem ody) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (swig ) (SPeciO teawa) ❑ $.TANK.REMOVED <br /> BUSINESS. AME IS rFACIITY NAME or DBA-Doug Buaioer M) 3. FACILITY ID: 1' <br /> v�¢ A eE7J°cIc 7H S. <br /> LOCATION WITHIN SITE(00kma0 431. <br /> MEEEENRVfANk DEStRI TION <br /> yst6mineWdin buildings and-la shall be submitted.to the local agency.) <br /> TANK ID#_r 412_ TANK MANUFACTURER 031- COMPARTMENTALIZED TANK ❑Yes No 434. <br /> 4(C$�( 6s`(J T/tuS C B Ya �avweea �e� ma w <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS <br /> 1 437. <br /> (YEARIMG) -212 21f 7 <br /> ADDITIONAL DESCRIPTION(Fm krnl ice only) 438. <br /> TANTPUSE 439 PETRO UM TYPE 440 <br /> 1. MOTOR VEHICLE FUEL 4 REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (tfchmked,con,l .Peaolaao Type) ❑Ib. PREMIUM UNLEADED [3 3. DIESEL [3 6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(RamllrsFdPFe ktramb lavmop'pees) 4421 CAS#(aom3lamdou Mrmi.h hFwntarypage) uz. <br /> ❑ 4. HAZARDOUS WASTE <br /> (IncWce Used"a <br /> ❑ 95.UNKNOWN <br /> TYPEOFTANK 01. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WATT WITH INTERNAL BLADDER SYSTEM 03. <br /> (Check one item only) MEMBRANE LINER [195. UNKNOWN <br /> 2. DOUBLH WALL INGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-Pmurytaak ❑L BARE STEHL . FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN 444. <br /> (Osck orc tem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: <br /> INPORCEDPLASTIC PRP W/100%METHANOL <br /> TANK MATERIAL-secondary tank 1. BARE STEEL . FIBERGLASS/PLASTIC S. FRPCOMFHBLEW/100%METHANOL U95.UNKNOWN 05. <br /> (Check me item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> S. CONCRETE <br /> TANK INTERIOR LINIIIG 0 L RUBBER LINED Lj 3.EPDXY LINING U S.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED N7. <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER <br /> Check one item ml <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC E195.UNKNOWN 443. DATE INSTALLED H9. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER <br /> fApplicable) [12.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 451 <br /> (Check all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM [13.FILL TUBE SHUT OFF VALVE_ <br /> ❑2.DROP TUBE ❑2.BALL FLOAT_ [14.EXEMPT <br /> 3.STRIKER PLATE <br /> IV:TANK LEAK DETECTION' <br /> description of the monitoring program shall be submitted to the tocala ency) <br /> IF SINGLE WALL TANK 453- IF DOABLE WALL TANK OR TANK WITH BLADDER 4A. <br /> (Cbmk all that apply) (Check one itemonly) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑11..VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSe ZONE B'2.CONTINUOUS INTERSTITIALMOMTORING <br /> ❑3.CONTINUOUS ATC [17.GROUNDWATER [13.MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457 <br /> gallons ❑Yes ❑ No <br /> UPCF hwfwm-b(1199)-.1/4 http://www.unido org Rev.02116/00 <br />