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,_,,iFIED PROGRAM CONSOLIDATED FORM,'. / TAMC: PR#: UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: (two pages per tank) Page i af3 TYPE OF ACTION (Clrrk onhl�mh') El SITE PERMIT ❑ 4AMENDED PERMIT ❑ SCIIANGFOF INFORVLATION ❑ 6THMPORARY SITE CLOSURE a� ❑ T PERMANENTLY CLOSED ON SITE ❑ 3RENEWAL PERMIT '(Spaify mases-em loyal 7) =' ❑STANK REMOVED 430 BUSINESS NAME(Samau FACILITYNAMEm DBA-Doing Basimas As) J FACILITY ID: PR#: LOCATION WITHIN SITE(Dpucw) UI PHONE 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 ID# 432TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 04 v^rea^.ooawR+n�ease re a e�awa�mnn. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(Fu Inom..,h) 439 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE "a ❑ 1.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If�Pnroleum T3,) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ Ic MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(yam Hvmdws M..k Immn-page) 441 CAS#(B Hvard Mn rule[nvccwn page) 442 ❑4.HAZARDOUS WASTE (InJa Used W) ❑ 95.UNKNOWN Id TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (CMrkwai�as) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN ❑ Z DOUBLE WALL ❑ 4.SINGLE WALL M VAULT ❑99.OTHER TANK MATERIAL-primary utak ❑ 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 444 (C9mk.Imn my) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ LBARE STEEL E]3,FIBERGLASS/PLASTIC 05.CONCRETE ❑95_UNKNOWN 445 (Chat:tar ken mly) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100'/.METHANOL REINFORCED PLASTIC(FRT) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED a47 OR COATING (Clea arc nen mly) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑6 UNLINED ❑ 99.OTHER (Fa1uJu,eoaly) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN "a DATE INSTALLED aa9 PROTECTION W APPLICABLE PROTECTION (CMA onal.m ) ❑4 IMPRESSED CURRENT ❑ 99 OTHER F1 2SACRIFICIAL ANODE (Fabwl ucmly) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(b mean ) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chale all mu apple) ❑ I SPILL CONTAINMENT ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A daaupuon Dane..mmna pmar.A.1L x snhmind m we IF SINGLE WALL TANK(Ch Aam apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) ICn>k ovmmn mly) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑T GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑W OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOMAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑ No UPCF(12/99 revised)