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UNIFIED PROGRAM CONSOLIDATED FORM U\V TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page I of ?-- TYPE TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (m konehemowy) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (SP Ifyreaw) (Spteify«uov) ❑ 8.TANK REMOVED BUSINESS NAME(seen,u FACB.frYNAME or DBA-Dow,,Baawea N) 3. 1 FACILITY ID: t 1 l LOCATION WITHIN SITE(optioned 431. I.TANK DESCRIPTION` (A sealed:plot pitut with the location of the UST system including buildings and)ancimarksshaRbesubmitted to the.local"agencv.) TANK ID# 432. TANK MANUFACTURER 433, COMPARTMENTALIZED TANK ❑Yes ❑ No 434. If•Yea-weplete ow Page for each Covmanmmt. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 4n (YEAR/MO) ADDITIONAL DESCRIPTION(For bol ate only) 438 IL TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑ In. REGULAR UNLEADED ❑2. LEADED ❑5. YET FUEL (IcheckN,wnplem Pwolam Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑to. MIGGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (tram Hmrdom Metetiela lvratwryP4e) 001. CAS#dte.Heoo&no Metm®hmreotmypage) u2. ❑ 4. HAZARDOUS WASTE O000 ea Ute4 Oil) ❑ 95.UNKNOWN a III.TANK CONSTRUCTION. TYPE OFTANK [11, SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM H3_ (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL INA VAULT 99. OTHER TANK MATERIAL-pr®oymrk ❑I. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN M4. (t1rY om aemonly) [12. STAINLESS STEEL [34. STEEL CLAD W/F'LBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL.-seeondary tank C]1. BARE STEEL 3. FBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.GIVER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE . TANK INTERIOR LINING I.RUBBER LINED 3.EPDXY ISNWG U 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2 ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER (Check one hem onl OTHER CORROSION 0 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT 1399.OTHER IfApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 1 TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Chink all that apply) ❑L SPILL CONTAINMENT ❑I.ALARM ❑3.FIS.TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT_ [:14.EXEMPT ❑3.STRIKER PLATE _ IV.TANK LEAK DETECTION (A.description of the monitoring program shall be submitted to the localagency.) IF SINGLE WALL TANK 453, IF DOUBLE WALL TANK OR TANK WITH BLADDER 454_ (Cheek ad that apply) (Check one 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 08.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V:TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE. ESTIMATED DATE LAST USED(YR/MOMAY) J55- ESTIMATED QUANTITY OF SUBSTM'CE REMAINING, 15G' TANK FILLED WITH INERT MATERJAL) 457 gallons ❑Yes ❑ No UPCF hwfwrc-h(1/99)-1/4 http://www.unidoes.org Rev.02/16/00