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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION I.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OFlNFORMAl10N O 7.ERM�NTLY CLOSED ON SITE dlo. <br /> (Chock ane nemonly) ❑ 3.RENEWAL PERMIT ❑ a.TANK REMOVED <br /> (Spaify rcaaOn) (Specifyrearoo) 1. <br /> BUSINESS NAME(Same o FACILITY NAME a -Dohs Bosiam Aa) 3, FACILITY ID: <br /> jr O &a S 5 431. <br /> LOCATION WITHIN SITE(Dwlo aq <br /> LI <br /> l I) 77 I.TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST tem includin buildings and Jland wks shall be COMPARTMENTALZ ED TANK agency.) <br /> No d3a. <br /> TANK ID# asz. TANK MANUFACTURER <br /> 7 If`Yet,"mrpkte nae page far each caaryertmcna. <br /> O(a 7 02� 4Js. TANK CAPACITY IN GALLONS ass. NUMBER OF COMPARTMENTS aim <br /> (YEAR/MO) LLED 6 ® o <br /> dJs. <br /> ADDITIO ALDESSIPTIO (For local we Only) _ <br /> fp'\ , II.TANK CONTENTS <br /> 440. <br /> TANK USE 439. PETROLEUM TYPE <br /> W1 [I1. MOTOR VEHICLE FUEL 1 REGULAR UNLEADED ❑2. LEADED [I 5.JET FUEL <br /> (Ifchecked,complete PNekum Type) <br /> Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> aal. CAS#(fraOliaadoaa Marcriabinrentayme) 442. <br /> C33. CHEMICALPRODUCT COMMON NAME(banlf-daoa Mae-d lonooOry page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Includo Uacd Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPEOF TANK 01. SINGLE WALL 3. SINGLEWALLWITH EXTERIOR 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM u3 <br /> (Check one item only) MEMBRANE LINER [195. UNKNOWN <br /> ❑2DOUB ❑LE WALL 4. SINGLE WALL IN A VAULT [199. OTHER 4 <br /> TANKMATERIAL-prina tank L. BA <br /> R <br /> E <br /> S <br /> T <br /> ❑u, FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN « <br /> ATIB <br /> (Check one ace,only) [12. STAINLESS STEEL ❑4. STEEL <br /> ORCEU IFIISTTC LFRPS ❑8. FRP C MPMETH.LE ❑99.OTHER: <br /> REINTANK MATERIAL-secondary tank ❑1. BARE STEEL 3. FBERGLASS/PLASTIC 8. FRP COMPTIBLE W11001%METHANOL [195.UNKNOWN 445 <br /> (Check one item only) ❑2. STAINLESS STEEL [14. REINFOC RCED LAD /FIRELASTC(FRP) ❑10.COATED STEEL13 9- FRP DABLE JACKET [199.OTHER <br /> ❑S. CONCRETE <br /> TANK INTERIOR LINING LR :' LINED 1.EPDXY LINING 5.GLASS I.LYLVG 95.UNKNOWN W6. DATE INSTALLED 47. <br /> OR COATING El 2.ALKYD LINING ❑ <br /> 4.PHENOLIC LINING 06-UNLINED <br /> ❑99.OTHER <br /> Check ane hem onl Ode. DATE INSTALLED H9. <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC ❑4.FIBERGLASS CU�R�MCED PLASTIC yy.OTHER PROTECTION PROTECTION ❑ <br /> If A licable ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTEC110N EQUIPMENT: YEAR INSTALL <br /> 452. <br /> (Check all that apply) ❑I.SPILL CONTAINMENT ❑2.SALL FLOAT_ ❑4.ELL E SHUT OFF VALVE EXEMPT <br /> ❑2.DROP TUBE <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be subalitted to the local agency.) 4M- <br /> IF <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLE WALL TANK (Check om item only) <br /> (Check all that apply) <br /> ❑L VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING IN ❑I.VISUALUOUS IN WALL TI VAULT IT <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) 06.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING <br /> [14.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING E]99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE a57. <br /> ESTIMATED DATE LAST USED IYR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑ Na <br /> ... .. -- Rev.02/16100 <br />