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J UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND_STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ &TEMPORARY TANK CLOSURE 430. (Omer coe to m oely) ❑ 3.RENEWAL PERMIT ,❑,y 'l.PERMANENTLY CLOSED ON SITE (Spall-) (Speufy remoN I[S S.TANK REMOVED BUSINESS NAME(Sune a FACR.cfY NAME or DBA-paiv¢emmm As) 9. 1 FACILITY ID: L LOCATION WITHIN SITE(opnbae0 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID#// 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes AN. m4. AD �,s1 ti� Y"Yea"compote arc pw for en%conpmsma DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) Uk1"bLt1dRP427 PRa� (f ODJ I ADDITIONAL DESCRIPTION(For meal are only) 33A It.TANK CONTENTS TANK USE 439_ PETROLEUM TYPE am ❑ 1. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifcheteq armlem PewlnnoTypc) C1 lb. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (hum Hezerdom Matmvls Invavorylege) MI. CAS#Ilium Hemdom Madly 1...,page) 442- ❑ 4. HAZARDOUS WASTE (Lelwm uee6 a0 95.UNKNOWN IIL TANK CONSTRUCTION - TYPEOFTANK ❑1. SINGLE WALL. ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one immonly) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIA.-primus wit I. BARE STEEL ❑3. FIBERGLASS/PLASTIC Ll 5. CONCRETE D 95.UNKNOWN a��`` ua. (CmerJcemhemoWy) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS El S. FRP COMPATIBLE CK99.OTHER: Kpla.fL/Its REINFORCEDPLASTIC W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 8. FRP COMPTIBLE W/]00%METHANOL ❑95.UNKNOWN "S. (Cheek oro rtem only) ❑2. STAINLESS STEEL[14. STEEL CLAD WOBERGLASS ❑9. FRP NON-CORRODABLE JACKET 1z 99.OTHER_ REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 441. OR COATING [12.ALKYD LINING [14.PHENOLIC LINING jq6.UNLINED ❑99.OTHER Click om imm Del OTHER CORROSION Ll 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC C195.UNKNOWN "a. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER f Erabk 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. 1 TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 952. (Cheek n0 that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT ❑3.STRIKER PLATE _ W.TANK LEAK.DETECTION (A description of the monitoring program shall be submitted to the local agency) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one imm only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑S.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 [:17.GROUNDWATER ❑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 DATE{ LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAM'MG 456. TANK FILLED WITH INERT MATERIAL, 457. IQt.�b rC Q gallore XYes Cl No UPCF hwtwre-b(11")-1/4 http://www.unidocs.org Rev.02/16/00