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kS gl�UNIFIED PROGRAM CONSOLIDATED FORM D 4 TANKS -UNDERGROUND STORAGE WANKS - TANK PAGE I (TFageag Pages per tank) of_ TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE /39. (Check one her,only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify rcuon) (Specify reason) ❑ B.TANK REMOVED BUSINESS NAME(Seane as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY ID: I. W/NE CDUMTizY STRT/oN Sg �/ LOCATION WITHIN SITE(optional) 431. I l i r kE 77- LE p-7 P"- -f L.tt/ c I L O l- r C A I.TANK DESCRIPTION (A scaled plot plan with the locatioil of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 432. TANK MAN UFACTURER 433. COMPARTMENTALIZED TANK ❑Yes No 434, OS0O 2 If"Yee,"cowlelconepegefarmchconnipoeneat. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 4J6 NUMBER OF COMPARTMENTS 437. (YEAR/MO) Lq ADDITIONAL DESCRIPTION(For low me nnly� 439. 3 : II.TANK CONTENTS _ ,... TANK USE 439, PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED [15. JET FUEL (If ch4ckd,nosrplcte PproWun Typo) [31b. PREMIUM UNLEADED QX3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Barardous Materials Inventory page) 441. CAS#(flans Haa &w Materials Inventory page) M2. Q 4. HAZARDOUS WASTE (lockiWa Uud oil" Q FS.VNK NOW». III.TANK-CONSTRUCTION san`:rlr sa:, "n TYPE OF TANK ❑ I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER 095. UNKNOWN 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 4N. (Clack oro nem only) [12. STAINLESS STEEL 94. STEEL CLAD W/FBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/1000/6 METHANOL TANK MATERIAL-secondaty tank EI 1. BARE STEEL [13. FIBLA ERGLASS/PSTIC ❑B. FRP COMPTIBLE W/100'/o METHANOL 095.UNKNOWN as. (Check one item only) Q 2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET Q 99.OTHER REINFORCED PLASTIC(FRP) Q 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑ .GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING W6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN Ma. DATE INSTALLED a9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER fApplicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑L SPILL ON7ENT I.ALARM [13.FILL TUBE SHUT OFF VALVE El 2,DROP TUBE W'2.BALL FLOAT ❑4.EXEMPT [13 STRIKER PLATE IV.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 one item only) 1 ❑1. VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MIG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) [12. AUTOMATIC.TANK GAUGING(ATG) ❑6.VADOSE ZONE P,2.CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUS ATG ❑.7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING [j 99. OTHER V,TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. Sallow ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoemrg ' ' I' ' Rev.02/16/00