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" UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (rya pages per tank) <br /> Page _ of <br /> TYPE OF ACTION VVV��V 1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGEOF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check ons them only) 0 T. PERMANENTLY CLOSED ON SITE <br /> 0 �� <br /> 3.RENEWAL PERMIT (Speay meson-for local we only) (Spiyrg <br /> erchae-,or foul use oMy) 0 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busaress As) FACILITY 10 4 ) <br /> DD/34oq <br /> LOCATION WITHIN SITE(OpSamg 431 <br /> Y C <br /> I.TANK DESCRIPTION <br /> TANK LOA TANK MANUFACTURER / �/J COMPARTMENTALIZED TANK D Yea D No <br /> U K-1. It-Yes'.Complete ane page for eac comparMenl <br /> DATE INSTALLED(YEARJMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> g Do <br /> ADDITIONAL DESCRIPTION(For local we only) <br /> It.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 0 1. MOTOR VEHICLE FUEL Cl 1a. REGULAR UNLEADED ❑ 2. LEADED 0 5. JET FUEL <br /> (Irmanad,,complete PNratoum Type) D Ito PREMIUM UNLEADED 0 3. DIESEL 0 6.AVIATION FUEL <br /> 0 2. NON-FUELPETROLEUM 11 sc MIGGRADEUNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> 0 3. CHEMICAL PRODUCT <br /> 0 4 IARDOUS WASTE(Ir hahu, COMMON NAME(/mm Hazardous Mafenals lnwnhory page) CAS A(from Hazardous Maledals lmsnfaq page) <br /> used an <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1, SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Crock anelfem only) ❑ 2. DOUBLE WALL EKTERIOR MEMBRANE LINER 1195. UNKNOWM <br /> 0 4. SINGLE WALL IN A VAULT <br /> ❑99 OTHER <br /> TANK MATERIAL-phmary tank 1 BARE STEEL Cl 3. FIBERGLASS I PLASTIC 0 5. CONCRETE 1:195. UNKNOWN <br /> (Check are nem only) 0 2. STAINLESS STEEL 04. STEELCLADWIFIBERGLASS 0 a. FRP COMPATIBLE WI100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL.separates,lank 0 1 BARE STEEL D 3. FIBERGLASS I PLASTIC D S. FRP COMPATIBLE Y#100%METHANOL 095. UNKNOWN <br /> (Ohed arodonnonly) 11 2. STAINLESS STEEL 0 4, STEEL CLAD WIFIBERGLASS 0 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 11 10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RU88ER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOM433 DATEINSTALLED <br /> OR COATING <br /> 0 2. ALKYD LINING Cl 4. PHENOLIC LINING D 6 UNLINED 0 99. OTHER <br /> (Check one item o (Forbcal uaeOTHER o ) <br /> PROTECTION <br /> IF ON 0 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 1199. OTHER <br /> (QMCkcantatas.only) ❑ Z. SACRIFICIAL ANODE (Forbcal use orgy) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlauduae eny) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Gad as that apPN) <br /> ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE ❑ 2. BALL FLOAT 0 4, EKEMPT <br /> 0 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Crack ak that a IF DOUBLE WALL TANK OR TANK WITH BLADDER Crack one ahem only) <br /> D 1, VISUAL(E)POSED PORTION ONLY) D S. MANUAL TANK GAUGING(MTG) D 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> D 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ B. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑N. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLEOWTH INERT MATERIAV <br /> galb a ❑ ❑ <br /> Yes No <br /> 731(01 <br /> CUPAFORM(4199) • . Formerly SVJRCB Form 8 <br /> I <br />