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04/17/2007 09:24 916-373-1172 WALTf7N ENGINEERING PAGE ,y5 0 M 1/n UNIFLEA PROGRAM ANKS OLIAA 1 Fb FORM "iq I I5'�v 7 K UNDERGROUND STORAGE TANKS - TANK PAGE 1 l (Two pages per tank) Page I of 2 TYPE OF ACTION ❑ I.NEW PERMIT 0 4,AMENDED PERMIT 0 5,CHANGE OF INFORMATION 0.TEMPORARY TANK CLOSURE qaa, (Check one item ealy) ❑ 3.RENEWAL.PERMIT ❑ 7,PERMANENTLY CLOSED ON SITE (spam,mnwN (6pttifyre.non) ® R.TANK REMOVED BUSINESS NAME(Snme at FACILITY NAME a,DDA Dema SWIM,Ar) ). FACILITY ID: .Toe's TTBVCI Plaza I !; LOCATION WITHIN SI'I'F-(Opannnp 431 .TI'A!iNK I CRIPrTON 4 scaled .otelan 4yith'thblceat(oilofllteUSTsystemin6ludiAgedildiHgsandlepdmark<:ahallbc,submittcdto•thclbcaY an TANK 11)4 4a 1, TANK MANUFACTURER 431. COMPARTMENTALI7EDTANK EFycs Na 434, U13known If'Ye.'cempIme em Px,a Por men eoep.mneem. DA ,INSTALLED 465, TANK CAPACITY M GALLONS 436 INUMBIZKOFC MPARTMF:NTS (YEAR/MO) 437 Unknown 500 ) ADDITIONAL DESCRIPTION(For IM.I aaenmy) 458 tF.1'.AhTF4 CONTf"1�1"I!S' TANK USE 4.19. PETROLEUM TYPE 440. ❑ I. MOTOR VEHICLE FUEt ❑la, REGULAR UNLEADED ❑2, LEADED C15. JET FUEL pfrAeckrd,mmplete Mmleum Typo) ❑ H,, PREMIUM UNLEADED El, DIESEL ❑6, AVIATION OAS ❑ 2, NON-FUEL PETROLEUM ❑Ia. N4tt*RADEUNLEADED UI 4. GASOHOL. 099.OTHER.Unknown ❑ 3 CHEMICAL PRODUCT COMMON NAME (from Hne.rdmi.Mntml.le imonwry onset 441 CAS4(ff.Ha...rdmon Mvt M.Ix lnmem,Page) „z. ❑ 4. HAZARDOUS WASTE. Unknown 0nehdax Ua l nip 3 95.UNKNOWN C."SAN�C=T_t S I'll TIO" TYPE pFTANK t SI OLE WALL 3, SINOLE WALL WITH EXTERIOR ❑5, SINOLE WALL,WITH INTERNAL n1.ADDFB SYSTEM 443. (Check one item only) MEMBRANE 41MER ❑95, UNKNOWN 0 2. DOUB4E WALL 4. $1NOLE WA4L IN A VAULT 99. O7HGR TANK MATERIAL-pommy mak 0 L BARE STBEL 3, FTBEROLA$9/PLASTTC 5. CONCRETE Cl 95,UNKNOWN 444. Minot,are tom nety) 0 2. STAINLESS STEEL ❑4, STEEL CLAD W/FERRGLASS ❑R, FRP COMVATIBLE L199.oTgnR, REINFORCED PLASTIC RP W/1 M%METHANOL A MATERIAL-secondary tank L BARE STEEL 3. FIBERGLASS/PLASTIC ria, FRPCOMPTIBLEWTODe.AMBTHANOL 95.UNKNOWN 445. (Check oro ikne only) 0 2. STAINLESS 57EEL ❑4. STEEL CLAD W/FtBEROLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(PRF) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑I.RUBBER LINED ❑3.EPDXY LINING ❑5.OI,A•S LINING ®95.UNKNOWN 446. DATE M$TAI-LED a>. OR COATING [12,ALKYD LMINO ❑4.PHENOLIC LINING ❑6.UNLINED ❑99,OTHER Cluck one item only) OTHER CORROSION u I,MANUFACTURED CATHODIC 0 1,FIEEROLABS REINFORCED PLASTIC 3 03 1NRNOWN Mx. DATE TNSTALLED m9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If licable [12.SACRIFICIAL ANODE SPLW.AND OVERFILL YEAR INSTALLED 450. TYPE 46I. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 455. (Cheek all that apply) 0 I.SPILL CONTATNRffNT Unknown :11.ALARM _ 0 3.FILL TUBE SHUT OFF VALVE Link ❑2,DROP TUBE Unknown :12.BALL FLOAT_ [14 EXEMPT 023.STRIKER PLATE tlnknown rSdESiCY'I ntrpitlCfhm:manitlirl'n'gp"van",6k11bit 5ErilrlklkNm die locai,ngcney.) AN IF SINGLE WALL TK 45 D. IF DOUBLE WALL TANK OR TANK WITH BLADDER 4U (Check all that apply) (Check one item wily) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTC) ❑ I,VISUAL(SINGLE WALL IN VAULT ONLY) ❑d.AUTOMATIC TANK GAUGING(ATC) ❑6,VADOSE 70MV ❑2.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG 0 7.GROUNDWATER 0 3.MANUAL MONITORING ❑d.STATISTICAL INVENTORY RECONCILIATION 0 a.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. OTHER Unknown V bI ;ICLO5T TAH 'WlAT1iSk�!✓ �EXMANKN'I CLrOSURF IN PLACE FgTIs6ATEo DATE LAST USED(YRlMO/DAY) °f$• ESTIMATED QUANTITY OF SUBSTANCE REMAININp 45a tnNK PILLED WTTH INERT MATERIAL? 457. canvas ❑Yes 0 No IIPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16AID