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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 1 (Two pages Per tank) Page-#-of� TYPE OF ACTION ❑d�a/J NEW PERMIT ❑ 4.AMENDED PERMIT [:35.CHANGE OF INFORMATION [16.TEMPORARY TANK CLOSURE 430. (Chid one nem only) a"f 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (spaifyremn) ❑ 8.TANK REMOVED BUSINESS NAME(Same u FACILITY NAME or DBA-Doing Baamess Aa) 3. FACILITY ID: 1. CaSTRuc�eWAS 4C dbaTmcoTrzuc�Plrt LOCATION WITHIN SITE fopfioN0 Sec 51 'k .31. I.TANK DESCRIPTION (A scaled plot.plan with the location of the UST system including buildings and landmarks shall be submitted to the local y.) TANK m##� 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK a e Yes 0 No 434. / A10P6,91V WF1D/!46- If'•Yea;'cor�glem orc page for wch compannent. DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS a37. (YEAR/M°' 1910 /z,coo Z ADDITIONAL DESCRIPTION(For kcal aee omy) 438 IL TANK CONTENTS TTAANK USE 439. PETROLEUM TYPE "01. MOTOR VEHICLE FUEL {s8 Erle. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (IFtlackad.rorrPkte N.I.m Tra) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑It. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ham Ru.rdoaa mamrkk i.,caory page) T. CAS#(aom Haas -wcrkk Inventorypage) 442. ❑ 4. HAZARDOUS WASTE 0nalade.Uaedoi0 REL1alar- EIMLFE34DED9ASnLin/ ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441. (Check one itemody) J MEMBRANE LINER ❑95. UNKNOWN (yJ . DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-prmaryw 1. BARESTEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN a4. (Chat ora hemenly) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/I�METHANOL TANK MATERIAL-smo Bary tank 1. BAREST EL J] FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN u5. (Checkone item only) ❑2. STAINLESS S'T'EEL IO•. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [3 99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 I.RUBBER LINED 3.EPDXY LINING GLASS LINING 95.UNKNOWN M6. DATE WSTALLED "T OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING Iff 6.UNLINED ❑99.OTHER p (Check one item on q p OTHER CORROSION 1.MANUFACTURED CATHODIC El 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 4as. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfApplicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL�� YE R TALLED 459. TYPE 451. OVERFILL PROTECTION EQ MENT: YEAR INSTALLED 42 (Check all We[apply) Ki DROP TUBESPILL AAIMENT 17 It X El 2.BALL 1.ALARM OAT_ ❑4.EXEXEE SHUT OFF VALVE 3.STRIKER PLATE W.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 WITH BLADDER 454. (Check all that apply) (Check..item only) ❑I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑/I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE W2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.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 456, TANK FILLED WITH INERT MATERIAL? 451. gallon. ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00