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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> „ n UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> {CIX�1 (Two pages per tank) <br /> TYPE OF ACTIONPage_oC_ <br /> EW PERMIT El 4,AMENDED PERMIT Cl 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE <br /> (checkomhcmonly) El3.RENEWAL PERMIT 110. <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (spedry,euon) (specify reuon) .TANK REMOVED <br /> BUS[NESS NAME(Sameu FACILITY NAhOi a,DBA-Doing Business At) 1, FACILITY ID: "' <br /> ��/�d Q r�:•: I. <br /> LO ATION WI INSITE(apuon,�) /^ T <br /> 43 L <br /> I.TANK DESCRIPTION' <br /> (Ascaled lot plan with the location of the UST system mcludin buildlogs and landmarks shall.,be submtttedtp the 1=1 agency'.) <br /> TANK IDN 431 TANK MANUFACTURER ol. - ' <br /> ��� 1 j COMPARTMENTALIZED TANK ❑Yes o 4y4, <br /> DATE INSTALLED 415. u••ye;'wmplaa ana pay.6,e.ch mmpanment <br /> (YEAR/MO�/ � TANK CAPA�Cl/TY/M4/G�AjLlLJ/O�N�S� /j 41s. NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Fo,mc,l uae only) <br /> 437 <br /> 418. <br /> I1..TANK COI)4ZENTS' <br /> TANK USE 419. PETROLEUM TYPE <br /> ❑ L MOTOR VEHICLE FUEL ❑In. REGULAR UNLEADED 1:12. LEADED 440, <br /> Ofehuk<q wmplwe Pnmkum type) ❑5, lET FUEL <br /> ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUELPETROLEUM ❑IQ. MIDGRADE UNLEADED El 4. GASOHOL <br /> ❑ 3. CHEMICAL PRODUCT ❑99.OTHER: <br /> COMMON NAME(tram HasvdomMnerklslnventon vase) 4i1' CASH(6om Ha,ardoua Muviala lnvenarypaye) 442. <br /> ❑ 1, HAZARDOUS WASTE <br /> (IncW4u Uvd Oil) <br /> -4:f-95.UNKNOWN <br /> III.TANK CONSTRVOn'ON <br /> TYPEOFTANK . SINGLE WALL ❑3 SINGLE WALL WITH EXTERIOR <br /> (Check on<item only) MEMBRANE LINER ❑S, $MGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> ❑2. OUELE WALL 4. $MGLE WALL INA VAULT ❑95. UNKNOWN <br /> TANK MATERIAL-prim,ry lm ARE STEEL 99. OTHER <br /> ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN <br /> (Ch«k on<kem only) ❑2. STAINLESS STEEL ❑4, STEEL CLAD W/F18ERGLAS$ 4d1' <br /> ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> TANK MATERIAL- REINFORCED PLASTIC FRP W/IOOX METHANOL <br /> uwndary tank I. BARE STEEL ❑J. FIBERGLAS$/PLASTIC 8. FRP COMPTIBLE W/100%MEIHgNOL 95.[MKNOWN u5. <br /> (Ch«k on i¢m only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WBIHERGLASS ❑9, FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> TANK INTERIOR LINING 1.RUBBER LINED J.❑EPDXY LINMGE 5.GLASS LINING UNKNOWN 446. DATE INSTALLED 411. <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNWNID <br /> (Chock one item oN ❑99.OTHER <br /> OTHER CORROSION ❑L MANUFACTURED CATHODIC 7.FIBERGLASS REINFORCED PLASTIC UNKNOWN 448. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT DATE INSTALLED 449. <br /> IfA Iicable 2.SACRIFICIAL ANODE ❑99.OTHER <br /> SPILLA11 OVERFILL YEAR INSTALLED 150. TYPE BI. OVERFILLPROTECTIONEQUIPMENT:- YEARMSTALLED 45x. <br /> (Chock all t t ply) ❑I.SPILL CONTAINMENT - <br /> ❑2.DROP TUBE ❑ I ❑ <br /> .ALARM 3.FILL TUHESHUTOFFVALVE <br /> 1 STRIKER PLATE ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring. rogram shal46e submitted to.the locals cn <br /> IF SINGLE WALL TANK - _X�): <br /> (Chock ill et apply) <br /> 151, IF DOUBLE WAgLL TANK OR TANK WITH BLADDER 454. <br /> UMTG AL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING (Check one item mdy) <br /> ( ) C)I.VISUAL(SINGLE WALL M VAULT ONLY) <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑J. CONTINUOUS ATG C]],GROUNDWATER (:13 <br /> 3,MANUAL MONITORING <br /> 04.STATISTICAL INVENTORY RECONCILIATION ❑g,TANK TESTING <br /> (SIR)r BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK-CLOSUREINFO'RMA PION/ PERMANENTCLOSURE IN PLACE <br /> ESTIMATED <br /> 'DAT/E�LAST USED YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 45°- TANK FILLED WITH INERTMATERIAL7 457, <br /> C/.1 IJC � is D gallons ❑yes �-lo <br /> UPCF hwrwre-b(1/99)-1/4 litip://www.unidocs.org Rev.02/16/00 <br />