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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> tank <br /> TYPE OF ACTION .NEW PERMIT Pege_Of <br /> ❑ 4.AMENDED PERMIT(CTeek one item only) - �] 7.RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q 6.TEMPORARY TANK CLOSURE <br /> 430. <br /> (Sp.dry r..w°) ❑ 7.PERMANENTLY CLOSED ON ITE <br /> BU INESS NAME(Sm u FA (gerfI n.mn) ❑ 6.TANK REMOVED <br /> ' CILITy NAME er DBA-Doing BminueFACILITY ID: , �� <br /> LOCATION WITHIN SITE(0inie..1) I 1. <br /> Jt,'e),Z/f 411. <br /> I.TANK DESCRIPTION' <br /> ca'led 0t 180 with the 1020'ott.o£the UST system includingbuildings and <br /> TANK ID A 412 TANK MANUFACTURER )a0dnlafks shall;be submtttW:4othe 1 I, <br /> i 411. COMPARTMENTALIZED TANK e0 <br /> DATE INSTALLED Year No <br /> (YEAR/MO) �cJ�� 1 4ss. TANK CAPACITY IN GALLONS U6. If-Ye4mmplat.e°.p.g.f°1. . n4. <br /> nNTS <br /> NUMBER OF COMPARTMENTS <br /> 1` �./f.1 1 <br /> ADDITIONAL DESCRIPTION 41 <br /> (For bc.l um only) <br /> 418. <br /> T KUSE <br /> 439. I7i:'TAYICtlEly : <br /> PETROLEUM TYPE <br /> I. MOTOR VEHICLE FUEL r��� <br /> (lf11mck.d,mmplate PatmhumType) f)� REGULAR UNLEADED CI 2. LEADEp440. <br /> ❑lb. PREMIUM UNLEADED ❑5 JET FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑3. DIESEL [16. gV1AT10N GAS <br /> ❑le. MIDGRADE UNLEADED <br /> CI 3. CHEMICAL PRODUCT Q 4. GASOHOL <br /> COMMON N [199.OTHER: <br /> El 4. HAZARDOUS WASTE AME (Imm R,.&a,M....WelnvenWry page) 441. CASk(from H.wdom Material.Inventory ge 493. <br /> (1.1'eiae used 010 ) <br /> ❑ 95.UNKNOWN <br /> TYPE OF TANeck K IIIt,, I}�g4�,,i ` .. <br /> (Chone item only) . SINGLE WALL ❑3, SINGLE WALL WITH EXTERIOR ❑5, INT". .., <br /> MEMBRANE LINER SMGLE WALL WITH ERNAL BLADDER SYSTEM 441. <br /> TANK MATERIAL_ 2. DOVBLE WgLL 4. SINGLEWALL IN A VAULT ❑95. KNOWN <br /> primatytw ' BARE STEEL ❑7. FIBERGLASS/PLASTIC99. OTHER <br /> (west oM item oely) 5. CONCRETE <br /> ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS I-r95.UNKNOWN 444. <br /> TANK MATERIAL,_secondary REINFORCID PLASTIC FRP ❑g' FRP COMPATIBLE 1399.OTHER: <br /> tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC W/IOOY.METHANOL <br /> (Check one item only) ❑2. STAINLESS STEEL❑4, STEEL CLAD W/EIBERGLASS g FRP OMPTIBLE Wg00•/,METHANOL .UNKNOWN <br /> ❑9. FRP NON-CORRODABLE 445. <br /> TANK <br /> REMFORCID PLASTIC(ERA) ❑!0 COATED STEEL ❑99. <br /> TANK INTERIOR LININGk.RUBBER LINED 5. CONCRETE OTHER <br /> Cl COATING ❑2.ALKYD LINING 3.EPDXY LINING 5.GLASS LINING <br /> Check ane itcm and ❑4.PHENOLIC LINING 6,IINLINID 9s.UNKNOWN 446. DATE INSTALLED 447. <br /> OTHERCORROSION ❑.99.OTHER <br /> PROTECTION I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN <br /> IFA Nesbitt PROTECTION ❑4.IMPRESSED CURRENT 44e. DATE INSTALLED 449, <br /> 2.SACRIFICIAL ANODE ❑99.OTHER <br /> SPILL AND OVERFIt.,Iy)LL YEARINSTALLED 450. TYPEOVERFILL PROTECTION EQUIPMENT; YEAR INSTALLED 451 <br /> (Chak ill tlut.pyly) ❑I.SPILL CONTAINMENT <br /> ❑3.DROP TUBE y� ❑ .ALARM _ ❑3.FILL TUBE SHUT'OFF VALVE <br /> 3.STRIKER PLATE ❑2.BALL FLOAT_ ❑4,EXEMPT <br /> IV TANKLEAK Y)E . � -(ylj <br /> (A.descr3 hgmof the monitoring program shalkbdAubimUtedtp;theIocal ageilc .1 <br /> IF SINGLE WALL TANK ... <br /> (Cheek ill that apply) - �/- 453. IF DOUBLE W ALL TANK OR TANK WITH BLADDER 454. <br /> 111. VISUAL(EXPOSED PORTION ONLY) (JGS�MANUAL TANK GAUGING MTG (Cheek one item only) <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ( ) ❑1•VISUAL(SMGLE WALL IN VAULT ONLY) <br /> LMONIORIN <br /> ❑7.CONTINUOUS ATG ❑6'V'�OOSE ZONE Q 2.CONTINUOUS INTERSTITIg1 MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑7.GROUNDWATER [13.MANUAL MONITORINGC3 g.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> .TAItIC.CYvOS( `I <br /> �i4, OIy1 PEg7a$ UItE L•r1K <br /> ESTIMATED DATE LAS USED(YR/MO/DAY <br /> ) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT ATERIAL7 453 <br /> L) 41 G g.11em ❑Yee No <br /> UPCF hwfwre•h(1199)-1/4 <br /> httP://Www.unidocs.org <br /> Rev.02/16/00 <br />