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' la UNIFIED PROGRAM (UP)7ORM UNDERGROUND STORAGE TANKS - TANK PAGE 1 two pages Per tank Pae of TYPE OF ACTION [11.NEW SITE PERMIT A3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE (Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑6.TEMPORARY SITE CLOSURE ❑ 8.TANK REMOVED 430 BUSINESS NAME a a FACILITY NAME or 08A) FACILITY ID: 2 cx1jNo � 3LOCATIO WITHIN SITE(Olobora0I. TANK DESCRIPTION A scaled lot Ian with location s OfUSTs sem s InGudin buildin sand landmarks shall be submitted to the CUPA or PA.TANK ID# 432 TANKMANUF(ACTURER 433 COMPARTMENTALIZED TANK XA e5 If'Vas,complete one Page for each comparimeDATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 43s NUMBER OF COMPARTMENTSADDITIONAL DESCRIPTION(Fartont useonry) 11. TANK CONTENTS TANK USE 439 PETROLEUM TYPE1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If m hed complete Petrdeum Type) ❑ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL❑2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: � ❑3. CHEMICAL PRODUCT COMMON NAME 441 CAS# 442 ❑4. HAZARDOUS WASTE(Includes Used Oil) (fran Ha7ardaus Materials Inventory page) (from Harami Materials Inventory page) > / ❑ {025 95.UNKNOWN DI Se ' 69/,t 76 - 3`-- 6, III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL 1713. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER ((Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN 443 2. DOUBLE WALL 04. SIGNLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-bii ..y tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN ((Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS 0 8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER "Al REINFORCED PLASTIC(FRP) _ TANK MATERIAL-sewndary lank❑ 1. BARE STEEL ❑3. FIBERGLA55/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN ((Check we item only) 02. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [38. FRP COMPTIBLE W/100%METHANOL❑99.OTHER 445 REINFORCED PLASTIC(FRP) ❑10.COATED STEEL _ TANK INTERIOR LINING ❑ 1.RUBBER LINED 0 3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN DATE INSTALLED 447 OR COATING [3 2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER aas (Fn tical use only) Check one item onl OTHER CORROSION ❑1 MANUFACTURED CATHODIC3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN DATE INSTALLED 448 ON PROTECTION(IF APPLICABLE) PROTECTI4 IMPRESSED CURRENT 09 OTHER 448 (For local use only) Check one,tem onl 2 SACRIFICIAL ANODE SPILL AND OVERFILL (Check all that apply) YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 `P!LA SPILL CONTAINMENT �� LCL 'a1 ALARM 'C C32 DROP TUBE ❑2 BALL FLOAT ❑ 3 STRIKER PLATE ❑3 FILL TUBE SHUT OFF VALVE ❑4 EXEMPT IV. TANK LEAK DETECTION(Adeschption of themonitoring program shalt be submitted to thetocal agency.) i ' IF SINGLE WALL TANK(Cherkan thatapply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 I (Check one Item only) i C3 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 ^I,12 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER T❑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 DATET USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCEREMAINING d56 TANK FILLED WITH INERT MATERIAL? 457 ; 1 ❑Yes ❑ No ❑Yes ❑ No OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR INSTRUCTIONS FOR THE UNIFIED PROGRAM (UP) FORM UP Form(1/2000 Full Version) 31