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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (Two pages per tank) <br /> Page .Z of� <br /> TYPE OF ACTION 00/3.RENEWAL <br /> NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (chick am men only) 00/3.RENEWAL PERMI'P <br /> ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (specify-or) (Spmifyrtnop) ❑ 8.TANK REMOVED <br /> BUSINESS NAME Is.an FACILITY NAME.,DBA-Doing B-im..M) 3. FACILITY ID: 1. <br /> + STltuckWA-. T cdTivAc 3TRgckV <br /> LOCATION WITHIN SITE(opanm0 <br /> 431. <br /> See 51-k- I� Pt <br /> 1.TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall he submitted to the local age y.) <br /> TANK ID H 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes ❑ No 4x. <br /> G MobF-A" wEd-GING <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. <br /> (YEAR/MO) 1995 O, t�Dd z <br /> ADDITIONAL DESCRIPTION(For toral one only) 438 <br /> II.TANK CONTENTS <br /> TANK USE 439. PETROLEUM TYPE uo. <br /> p0 1. MOTOR VEHICLE FUEL ❑J Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (IfcamkW,mmpka Pcwkum Type) yJlb. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (ham Huardom MeredaB lmcm.ry p.ge) W 1. CASH(Rom Haaanlom M.ten.b Inventory page) 442. <br /> ❑ 4. HAZARDOUS WASTE <br /> (Iml.de.UsedOn P"Inlum (.tIV ICA DEDA50111yE <br /> ❑ 95.UNKNOWN J <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM -4437- <br /> (Check <br /> 41 <br /> (Check one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> I4f . DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER <br /> TANKMATERIAL-prhnarytaNe 1. BARESTEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE C3 95.UNKNOWN aa4. <br /> (Chock ow nem only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC FRP W/100%METHANOL <br /> TANK MATERIAL-secondary talk 1. BARE STEEL ,../3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN N5. <br /> (Checkone itemoNy) [12. STAINLESS STEEL by 4. STEEL CLAD W/FIBERGLASS [19. FRP NONCORRODABLE JACKET [199.OTHER <br /> REINFORCED PLASTIC(FRP) [110. COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 0 1.RUBBER LINED Ll 3.EPDXY LINING ,�55..GLASS LINING 95.UNKNOWN 446. DATEINSTALLEDN7. <br /> OR COATING El 2.ALKYD LINING [14.PHENOLIC LINING IEB.UNLINED ❑99.OTHER <br /> (Check ora item only) <br /> OTHER CORROSION 0 1.MANUFACTURED CATHODIC Ej 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED N9. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER <br /> (if Applicable) ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL-/ Y A ALLED I59. TYPE 451. OVERFILL PROTECTION EQ MENT: YEAR INSTALLED 452 <br /> (Check all that apply) p/1.SPILL CONTAINMENT ❑1.ALARM [ FILL TUBE SHUT OFF VALVE Liffs <br /> DROP TUBE ❑2.BALL FLOATV [14.EXEMPT <br /> 3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted ro the local c .) <br /> IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WItH BLADDER 454. <br /> (Check all that apply) (Check one item only) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑�II VISUAL(SINGLE WALL IN VAULT ONLY) <br /> [32.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE W2.CONTINUOUS INTERSTITIAL MONITORING <br /> [13.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING <br /> [14.STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. <br /> gallons ❑Yea ❑ No <br /> UPCF hwfwre-b(1/99)-1/4 http://www.unidOCLorg Rev.02/16/00 <br />