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� ia�9/oma- 12 aZ UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 1 TANKS IV-Pages Per tank) TYPE OF ACTION ❑I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION Pa nr- ❑ 6 TEMPORARY SITE CLOSURE O\ (4s tmetmmHl ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (5paity r,,.m-fm bml me mH) (Specify rnma-tar bnl,,.s mlrl a TANK REMOVED Ola BUSINESS NAME s .FACIL Y _pies .MI 3 FACILITY ID: - 40) LOCATION S (opume0 431 L TANK DESCRIM l (A scaled plot plat With the lotxtion of the UST system including buildings end landmarks shall be submitted to the local agency.) TANK R)# AAf/ 5• s0�2 TANK MANUFACTURER 433 COMPAR I h 14I LIZED TANK Yes o 4>. 07' Xe�es try.:.m.vl�a a.e a,as m�.rwwr. DATE INST C LED O) 435 TANK CAPACITY UIM ITY IN GALLONS 436 NBER OF COMPARTMENTS 437 0 DO ?L A DDMONIALDESCRIPTION(F. 433 II.TANK CONTENTS TA14K USE 439 ? , OLEUM TY E I. MOTOR VEHICLE FUEL la. REG UI 4R UNLEADED ❑2. LEADED ❑5. 3E1'FUEL (If mrkd weglae Pev9lwm Tyye) ❑Ib. PREMIUM UNLEADED3. DIESEL ❑ ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(6m I,a daa.s5.mnu aw o y we,l 441 CAS#(tom wm,M. ri 1,.mw y p.8e) 4 2 ❑4. HAZARDOUS WASTE. (Ix um all ❑95.UNKNOWN M. TANK CONSTRUCTION TYPEOFTANK 01, SINGLE WALL 0 3. SINGLE WALL WITH C3 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chad:me tem mly) EXTERIOR MEMBRANE LINER 095. UNKNOWN 2. DOUBLE WALL ❑4. IGNL.E WALL IN VAULT ❑99. OTHER TANK MATERIALL BARE STEEL . FIBERGLASS/PLASTIC Ll 5. CONCRETE 0 95. UNKNOWN a4 (Oak me dan mly) ❑2. STAINLESS STEEL ❑4. EL CLAD W/FIBERGLASS 08. FRP COMPTIBLE W/100'.METHANOL El 99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-raa.4.ry uat C3 I. BARE STEEL IFIBERGLASS/PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 445 (CtarY a.e tw.1y) ❑2. STAINLESS STEEL ❑ . STEEL CLAD W/FIBERGLASS [38, FRP COMPTMLE W/100.METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110 COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED El 3.EPDXY LINING �_ S.GLASS LINING 95.UNKNOWN as DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ,D(6 UNLINED ❑99 OTHER (Oat me iem w1Y) • (For bm l u4e mly) OTHER CORROSION ❑ I MANUFACTURED CATHODIC BERGLASS REINFORCED PLASTIC ❑95 UNKNOWN we DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Chat me tem mly) ❑2 SACRIFICIAL ANODE (Forbulam mlyl SPILL AND OVERFILL YEARINSTALLED 4" TYPE(teml we mly) 451 OVERFILL PROTECTION EQUIPMENT:YFAR INSTALLED 452 (Oeet.n iM,vply) I SPILL CONTAINMENT /401 '7 0 ALARM ❑3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE /"r Y 3 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE 4' N.TANK LEAK DETECTION(A dereriartm.fU,mmtarm8 preenm deo be mbmtre4 m Ae bul.smcy.) IF SINGLE WALL TANK(Cbeet.e w,r.ppH) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Oat me tem girl ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑ VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING C1 3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 NUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER N.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO(DAY) 453 ESTIMAT�$QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 `7 a C-�� gallons ❑Yes ❑ No UPCF(12/99 revised) %w/ 10 Formerly S WRCB Form B