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ADD lnond'A L ovA m Foe f-lqejL_IvI �( c7A O o©0 -71 -7 Neu UNIFIED PROGRAM CON50�ATED FORM\ Q016Iq/'f�3 TANKS ' V/UNDERGROUND STORAGE TANKS - TANK 1 (Two pages per tank) Page-L of_ TYPE OF ACTION ❑ NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (CMck am scm only) 13.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spxify moon) (Specify teawn) ❑ 8.TANK REMOVED BUSINESS NAME(S.a FACILITY NAME or DBA-Doing BBur..Aq� � 3. FACILITY ID: '- �tSTRko k WA SI�,TNcdbA 7iMto Iw1Ae(cr LOCATION WITHIN SITE(options) 431 5 PLaN I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the locala ency.) TANK ID#� -t'A Q (p TANK MANUFACTURER aJ1� COMPARTMENTALIZED TANK ❑Yes No 4.34. fila E-GD/n/Fr ff•wec nmmleeoK Pone fir,each mrva,mem. DATE INSTALLED 435 TANK CAPACITY IN GALLONS 036 NUMBER OF COMPARTMENTS 439. (YEAR/MO) /qql // ADDITIONAL DESCRIPTION(For local oho only) 4". IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440. ❑ I. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL 0fcheckeq oonriM,Pnmkum Tyre) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑66,,pVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL 1299.OTHER: W kS M MOTD 9= O�L- _/ 03. CHEMICAL PRODUCT COMMON NAME (6om BevNous Memrau In xmory page) 041' CAS#(6om H.nic.Mmeebiainm veory page) 4a2 pd 4. HAZARDOUS WASTE (Irclodes Used Oi0 wAs�r'E o / L- mf x:77kxC ' n/1A ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) �/ MEMBRANE LINER [195. UNKNOWN IyJ 2 DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-iorks,, BARE STEEL 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 95.UNKNOWN 444. (Chink ow hem oely) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP WIIOD%METHANOL TANK MATERIAL-secondary tank 1. BARESTEEL -3. FIBERGLASS/PLASTIC S. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN "5- (Clack.. 5. (Check ane item only) ❑2. STAINLESS STEEL pp. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODA13LE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL S. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED U 3.EPDXY LINING U 5 GLASS LINING 95.UNKNOWN N6. DATE INSTALLED 4Q. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING UNLINED ❑99.OTHER (Check one item on l ) OTHER CORROSIONLj I.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN 44s. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If licable 2.SACRI IAL ANODE SPILL AND OVERFILLY TALLED 450. TYPE 431. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑LSPILL CONTAINMENT g1.ALARM ❑3.FILL TUBE SHUT OFF VALVE_ ❑2.DROP TUBE 1791 2.BALL FLOAT_❑4.EXEMPT 3.STRIKER PLATE IV.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 W BLADDER 454. (Check all that apply) (Check otic item only) [11. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑ VISUAL(SINGLE WALL IN VAULT ONLY) [32. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.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 REMAINING MATERIAL? 4$T gallotu K No MAY 2 3 2003 UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org ENVIRONMENT HEALTH °•01" 00 PERMIT/SERVICES