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,,�IFIED PROGRAM CONSOLIDATED FORN.�,, ;fjjg(o <br /> TANK:PR#:UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#:er rank) <br /> TYPE OF ACTIONPage2of3 <br /> (CTsk wy aen my) ❑ 1 NEW SITE PERMIT ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> ❑ T PERMANENTLY CLOSED ON SITE <br /> ❑3 RENEWAL PERMIT [13.LTANK REMOVED 430 <br /> BUSINES NAME( ACa.t1YNAAB arD -Dome&emd N) ACD.ITY ID: pR#. 1 kl <br /> 6 lqf;g <br /> LDCATIO SlI h(opb ) _ <br /> 431 <br /> 2ij,i ..C. C�I fC PHONE <br /> I.TANK DESCRIPTION(A scaled plot plan with the location ofthe UST system including buildings and landnnrks shall be subo itied to the local agency.) <br /> TANK IDN 033 TANK MANUFACTURER s33 COMPARTMENTALIZED TANK ❑Yea R No 434 <br /> ATE INN I D(YEAR/MO) , 435 TANK CAPACITY IN GALIANS 436 NUMBER OF COMPARTMENTS 011 <br /> ADDITIONAL DESCRIPTION(Fwtaul,.aauY) d ) 438 <br /> H.TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE 440❑ L MOTOR VEHICLE FUEL [II a.REGULAR UNLEADED E] 2.LEADED ❑ 5.JET FUEL <br /> (IfmhNwnplar Permm Ti ) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL <br /> ❑2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADEUNLEADED <br /> ❑3.CHEMICAL PRODUCT E]4.GASOHOL �99 a mmcn :an•m <br /> COMMON NAME(6nm xa=vaa,n mamiwmma.yp, <br /> lcc) al CAS#ltm .aarma malmnxlany page) 442 <br /> ❑4.HAZARDOUS WASTE <br /> (1 U.adoio <br /> 95.UNKNOWN <br /> HI.TANK CONSTRUCTION <br /> TYPE OF TANK W I.SINGLE WALL ❑ 1 SINGLE WALL WITH ❑ S.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (OwE ore imnmdy) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN <br /> ❑2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER <br /> TANK MATERIAL-pnmarytank 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑95.UNKNOWN 444 <br /> (CLvkarc ban^nh) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTBLE W/100%METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ ".OTHER <br /> TANK MATERIA.-secondary lank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE <br /> ❑ 95.UNKNOWN as <br /> (O"d'®ab^n�f9 ❑ 2.STAINLESS STEEL ❑4.STEEL CLADW/FIBERGLASS ❑ S.FRP COMPrIBLE W/IW%METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LINING <br /> OR COATING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ S.GLASS LINING &95.UNKNOWN 4a6 DATE INSTALLED H1 <br /> (C�'wr bananN) ❑2ALKYD LINING ❑4PHENOLIC LINING ❑ 6UNLINED ❑ 99.OTHER <br /> (Pwlml ueaoly) <br /> OTHER CORROSION ❑ I MANUFACTURING CATHODIC <br /> ❑ 3 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN 44e DATE INSTALLED M9 <br /> PROTECTION H APPLICABLE PROTECTION <br /> (��a­owy) ❑ 2 SACRIFICIAL ANODE ❑4 IMPRESSED CURRENT ❑ "OTHER <br /> (Por lod uxody) <br /> SPILLANDOVERFI.L YEAR MSTALLE450 TYPE(] a.only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (O.mk+O tbt9vplY) ❑ I SPILL CONTAINMENT ❑ IALARM <br /> ❑ 2DROP TUBE ❑2 BAIL 3 FILL TUBE SHUT OFF VAL' <br /> ❑ <br /> ❑ 3STRIKER PLATE FLOAT ❑ 4 EXEMPT <br /> TV.TANK LEAK DETECTION(A d..ph.otde�pm�vn:w k .,,lode lural asacy.) <br /> IF SINGLE WALL TANK(O ka06w Wly) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Oaal.�.*) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑3 CONTINUOUS ATG ❑ ]GROUNDWATER ❑2 CONTINUOUS INTERSTITIA.MONITORING <br /> ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING <br /> (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER 3 MANUAL MONITORING <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE /� US (YR/MO/DAY) 455 ESTIMATED QUANTITY SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 451 <br /> V 0 L/ ❑Yea ENo <br /> UPCF(12/99 revised) <br />