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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> / TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE I <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4,AMEN E E IT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE <br /> �) 4]a. <br /> (Check one dem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> Itxr; )S�tcifymals) ❑ 8.TANK REMOVED <br /> BUSINESS NAME(Sam as FACILITY NAME or DBA I-'Doing Business As) ]. FACILITY ID: <br /> din/ fOUC• nJ <br /> LOCATION WITHIN E(opnon,ry <br /> 451. <br /> I.TANK DESCRIPTION <br /> (A scalcd Islot rilaus.with the location,Ofthe UST System includina buildings and landmarks shall be submined to the.)ocal agency.) <br /> TANK IDA 432. TANK MANy�FA�tCTUIu]. COMPARTMENTALPLED TANK Yes No <br /> NN wVW RE Yes,"eo rylne one Daae for each comp nm m. <br /> DATE INSTALLED 435. TANK CAPACITY M GALLONS 436. NUMBER OF COMPARTMEN75 <br /> (YEAR/MO) rr'' 417. <br /> fil;✓KsV9W A/ / 610M <br /> ADDITIONAL DESCRIPTION(For bol sar only) <br /> 4]s. <br /> 11.1-ANK CONTENTS <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑2. LEADED ❑5JET FUEL 440. <br /> D(checkod,compleie Petroleum Type) ❑lb. PREMIUM UNLEADED C. DIESEL , <br /> IK-2. <br /> 4. GASOHOL <br /> 2. NON-FUEL PETROLEUM ❑le, MIDGRADE UNLEADED ❑6. AVIATION?Y'.Z {'L/` <br /> ae <br /> ❑ 3. CHEMICAL PRODUCT ❑99.OTHER: / <br /> COMMON NAME (Iona Naz.nlons Mnedau mvemory rose) ul, CASN(som Haeudow Mne�aa lnveno <br /> ❑ 4. HAZARDOUS WASTE tlPaae) 442. <br /> (Ircbees Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1_1I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR f. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 41,. <br /> (Check one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> . DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-pdmoyunh I. W STEEL 3. FIBERGLASS/PLASTIC LJ f. CONCRETE95.(NKNOWN <br /> (chink Dee dem unlr) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS w4. <br /> ❑fl. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC FRP W/100%METHANOL <br /> TANK MATERIAL-secondary tank L BARE STEEL J. FIBERGLASS/PLASTIC 0 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN M3. <br /> (Check one item only) ❑2. STAINLESS STEEL IK4. STEEL CLAD W/FIBERGLASS ❑9, FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FAP) ❑ 10. COATED STEEL <br /> 5. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING LJ5.GLASS LININGA <br /> NOWN W. DATE INSTALLED N7. <br /> OR COATING [12.ALKYD LINING [14.PHENOLIC LINING <br /> Check one item on <br /> 6.UNLINED R <br /> OTHER CORROSION I.MANUFACTURED CATHODIC J.FIBERGLASS REINFORCED PLASTNOWN 441. DATE INSTALLED u9. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT <br /> (IfA limble ❑2.SACRIFICIAL ANODE ER <br /> SPILL AND OVERFILL YEAR INSTALLED 450. TYPE +51. OVETION EQUIPMENT: YEARINSTALLED 453. <br /> (Check ell that apply) �&_L SPILL CONTAINMENT $.I. J.FILL TUBE SHUT OFF VALVE _ <br /> ❑2.DROP TUBE [12. 4.EXEMPT <br /> J.STRIKER PLATE ❑ <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring rognim shall be submitted to the local agency.) <br /> IF SINGLE WALL TANK 45]. <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER +54. <br /> (Check all that apply) (Check one 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 'X2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3. CONTINUOUS ATG ❑7.GROUNDWATER <br /> ❑3.MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION Cl e.TANK TESTING <br /> (SIR)♦BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 4]5. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. <br /> gellow <br /> ❑Yes ❑ No <br /> UPCF hwfwre-b(1/99)-114 hilp://www.unidocs.org Rev.02/16/00 <br /> 0 <br />