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r � UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page-of- TYPE age_ofTYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT 9 5.CHANGE OF INFORMAMN ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one it,.only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specifyrtwon) ❑ B.TANK REMOVED BUSINESS NAME(Same a FACILITY NAME m -Doing Business As) 3. FACILITY ID: 1' LOCATION WITHIN SII ptic al)rb(O 431. 1117 E 1-e FT `l I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 013- COMPARTMENTALIZED TANK ❑Yes D No 434. 7 &-7nZ If`Y..rompleas ace Me for each coars artment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS t f p 411. (YEAR/MO) q8 o W ('� U b ADDITIONAL DESCRIPTION(For local use only) 438' 'S"7 WJLFLA-V R.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 449. Ip I. MOTOR VEHICLE FUEL a/ta. REGULAR UNLEADED 02. LEADED 05.JET FUEL (Ifchecked.aomplete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICALPRODUCT COMMON NAME (from Hazardous Materials Inventory page) UL CAS#(6mn Haadousmswrialslnwntmpage) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOW',; 2. DOUBLE W ALL ❑4. SINGLE W ALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank STEEL ❑3. FIBERGLASS/PLASTIC ❑S. CONCRETE 095.UNKNOWN444. (Check ox item only) [12. STAINLESS STEEL M14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC RP W/100%METILaNOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. ERP COMPTBLE Wi 100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING ❑ GLASS LC4ING El 95.UNKNOWN Ms. DATE INSTALLED MT Rot U OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 1� NLINED (199.OTTER Check one item onl _ OTHER CORROSION I.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.IJNTINOWN 446, DATE INSTALLED 449. PROTECTION PROTECTION ❑4.DORESSED CURRENT ❑99-OTHER (I f Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL / % Q YEAR INSTALLED 450. TYPE 451. OVrRFI�P PROTECTION EQUIPMENT:3PILL TUBE AR INSFF LLD VALVE 452. (Check all that apply) 0 1.SPILL CONT II�M fT V2.BALL FLOAT_ ❑4.EXEMPT ❑2.DROP TUBE ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK °53_ IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑I. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1J ISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE L7J2 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 I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/M YDAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 45T gallons []Yes ❑ No UPCF hwfwrc-b(1/99).114 http://w"iv.unidocs.org Rev.02/16/00