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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check me hem mly) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify rtww) (Specify Mem) 19 &TANK REMOVED BUSINESS NAME(Same r FACUTY NAME or DBA-Dwq Basims As) 3. FACILITYID: 1. SANGUINETTI FARMINGTON ) 7 LOCATION WITHIN SITE(opa.J) 431. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks sball be submitted to the local agency J TANK ID# 433. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ® No 434. UST-1 UNK If"Yq'ecmP�eemPeter =®PNm�. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) UNK 250 ONE ADDITIONAL DESCRIPTION(Fm tical...ony) 439. UNKOWN FUEL UST,DISCOVERED DURING DEMOLITION II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Bdeckad.conplee Peml Type) ❑It. PREMIUM UNLEADED 03. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ®99.OTHER-,_UNKNOWN ❑ 3. CHEMICAL PRODUCT COMMON NAME (eam Ilnmdam m.a.6lmnamy page) al. CAS#(6om n.>a Menials m.enmry peat) M2. ❑ 4. HAZARDOUS WASTE Outman gees On ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ®1. SINGLE WALL 0 3. SINGLE WALL WITH EXTERIOR 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM a3. (Check me item only) MEMBRANE LINER 095. UNKNOWN ❑2. DOUBLE WALL Q 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-pdmey teat0 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN 444. (Check me imn o y) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCP.DPLASTiC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank [11. BARE STEEL ❑3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 0 95.UNKNOWN 445. (Check mu item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 05. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN W. DATE INSTALLED M7. OR COATING ❑2.ALKYD LINING F14.PHENOLIC LINING N 6.UNLINED ❑99.OTHER Check one ilem and OTHER CORROSION 1.MANUFACTURED CATHODIC 0 3,FIBERGLASS REINFORCED PLASTIC Qg95.UNKNOWN 449. DATE INSTALLED 419. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (ITApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all dw apply) (]1.SPILL CONTAINMENT ❑I.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT 3.STRIKER PLATE IV.TANK LEAK DETECTION (A descri tion of the monitorinroa n 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 am item only) ❑1.VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.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. 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 436. TANK FILLED WITH WERT MATERIAL? 457. UNKNOWN IS gallons ❑Yes ® No UPCF bwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00