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_,IFIED PROGRAM CONSOLIDATED FORM U TANK: PRM: UNDERGROUND STORAGE TANKS - TANK PAGE i FAC M: (two pages per tank) Page 2 of 3 TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4AMFNDFDPIR\II I ❑ 5 CHANGE OF INFORM ATRl\ ❑6TEMPORARY SITE CLOSURE (Click ody iwmow5) '" '. �i7 PERMANENTLY CLOSED ON SITE ❑ 3RENEWAL PERMIT `(Sri+fvwa�s fu locafuaeanbl i8pc kreawa-Porlan O) „: ❑STANK REMOVED 430 BUSINESS NAME(S.w FACRITY NAME-DBA-Daisy Bin.Aa) FACILITY ID. PRM: 1 3 LOCATION WITHIN SITE(opuw) 6 � 431 VV Vim . r�Mdll r rS�t , SI '�L�HDNE 1.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 IDM 432 TANK MANUFACTURER 1 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 NKAUvv&J If-Yea',canpww one Wye fa each canpN t DATE JNSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 431 UN 1[n o y^'lll V Pj IL r*v-'X 1 ADDITIONAL DESCRIPTION(Far lain use arab) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE wo ❑ 1.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (1fm cu Purakvm T,,) ❑ I b.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME yro Hazud Mawnals[n%cnwry page) 441 CAS#If.Harmdmrs Mawdils Inemw.r page) 442 ❑4.HAZARDOUS WASTE (Imladea Used W) 95.UNKNOWN xDI.TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL El 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 x (C6ck�itrn mh) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ;Mrj.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Chak ur imm wrh) ❑2.STAINLESS STEEL ❑ STEEL CLAD WMBERGLASS ❑ B.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ W.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Click meimn aJy) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/iom.METHANOL REINFORCED PLASTIC(FRP) ❑ ID.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LMNGEl 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 441 OR COATING ICh J;crc iwn mk) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑ 99 OTHER (Fa kd use mb) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN Us DATEINSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Cheek.a-o*) E] 4 IMPRESSED CURRENT E]99 OTHER ❑ 25ACRIFICW.ANODE (Fu�'neenb'> SPILL AND OVERFILL YEARINSTALLE450 TYPE(Icalawmb) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Crack all ow eppb) ❑ I SPILL CONTAINMENT ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 HALL ❑ 4 EXEMPT ❑ 3STRIKER PLATE FLOAT N.TANK LEAK DETECTION(A desnipum offlw mWitanng pmgruo shad be wkbutW wwe Rod ag y) IF SINGLE WALL TANK(Chck W flus apph) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGNG(MTG) (Check cm.m ) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORYBECONCILIATION ❑ STANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ ??OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/_\Mp`/DAY) 455 ESTIMATED_QUTANTITY OF SUBSSTTA)NCE REMAINING 456 TANK FILLED �WITH W ERT MATERIAL? 457 �V n�w�J �Tv iL��PV [ Yes C]No it SAN( UPCF(12/99 revised)