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UNIFIED PROGRAM CONSOLIDATED FORM TANKS c H'i/IRoWEH tA!. HEAL 111 UNDERGROUND STORAGE TANKS-TANK PAI�ff S7 RVICF w a tank) Page-cif TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (t oink®mVy) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spsify cane) (SPeciB raeoa) ❑ S.TANK REMOVED BUSINESS NAME(e a PAOLITY NAME or DBA-Doing uumm Aa) 3, 1 FACILITY ID: rya LOCATION WITHIN SITE topdoal J L 431. I.'TANK.DESCRIPTION - (A scaled plot plan with the location:of the UST system including buildings and landmarIts shall be submitted to the local agency.) TANK ID# 432. TANK- 1MANUFACTURER 433 COMPARTMENTALIZED-TANK ❑Yes No 434. "•ST NY-ti 1�I If"YQ'm^9k�eom page hr arhcorryennrnt. DATE INSTALLED / 435 TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS (YEAR/MO) '1 Fn.(dbQAk A00Z• 1-5-1 W 437. ADDITIONAL DESCRIPTION(For bin an oray) 438. TANKUSE 439. PETROLEUM TYPE ,40_ ❑ I. MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL QlcB ckd.c�lee Peeokrnn TYpe) [I lb. PREMIUM UNLEADED 03. DIESEL ❑.6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑la. MIDGRADE UNLEADED ❑4. GASOHOL [3 99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om!Bernina Mecism towrory page) 411- CAS#(6om Hsar4oa t,4,...:.i.tnvemary page! u2. ❑ 4. HAZARDOUS WASTE Uvcmda Used Dir, 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL [33, SINGLE WALL WITH EXTERIOR :15 SINGLE WALL WITH INTERNAL BLADDER SYSTEM +43. (Check om Bern only) MEMBRANE LINER C395. IINKNO WN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-proory eek f. BARE STEEL ❑3. FIBERGLASS/PLASTIC 05. CONCRETE 095.UNKNOWN 444. (m one k ordy) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WNIBERGLASS ❑8. PRP COMPATIBLE Qr99.OTHER: REINFORCED PLASTIC FRP W/I00%METHANOL TANK MATERW.-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 8. FRP COm PTIBLE W/100%METHANOL 95.UNKNOQQWNQQ��,�,��40.5. (Checkoneiremooly) El 2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS [19.9. FRP NON-CORRODABLE JACKET' Q-99.OTRER�' REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING I.RUBBER LINED U 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED u7. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING Q6.UNLINED [199.OTHER Cheek om Bain oN OTHER CORROSION El I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN W4 DATE INSTALLED u9. PROTECTION PROTEC"ON [14.IMPRESSED CURRENT ❑99.OTHER If Iicable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT ❑I.ALARM _❑3.FILL TUBE SHUT OFF VALVE_ ❑2.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT ❑3.STRIKER PLATE IV_.TANK LEAK:DETECTION: (A description of the monitoring program shall be submstted!to the;loeal agency) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454, (Check all that apply) (Check ore Tem ody) ❑L VISUAL(F XPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MID) ❑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. STAIIS71CAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099.OTHER V.TANKCLOSURE`INFORMATION/ PERMANENT CLOSURE IN PLACE - ESTIMATED DATE LAST USED(YR/MO/DAY) 4$5 ESTIMATE/D�QUAMITY OF SUBSTANCE REMAINING 456' TANK FILLED WRH INERT MATERIAL? 4$7' Iq�(3 S k/ gallon 4Yea C3 No UPCF hwf*m-b(1/99)-1/4 http://www.unidomarg Rev.02/16M