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{ rye/ 1k!�/ V � k .. UNIFIED PROGRAM CO1tiSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE; 1 ('i rates per tank) TYPE OFRCiff7N ❑ l.N£H'PERMfT ❑ 4,AIafENDt D YIiRMIT 5.CHANGE OF INFORMATION Page of {(:heck om perm°�Y) ❑ 3.RENEWAL PERtvi1T ^- �� Cr.II� Q 6.TP.1ViPORARY FANK CLOS[fRE 430 ❑ 7.PERMANIEN $USINESS NAME(S.u FAMIfY NAME or DIM- (SPL'IfY meson} TLY CLOSER ON SITE (Spatify ecmaa) ❑ $,TANK REMOVED nSa nIN I'll 3, FACIL Y ID: OCA To _�SjT>r 471 7T,1n;I{ 51-WV.RI$ fp4noflhtheIuc9tioflbf:heUsI Yat#1ilrmcl TANK lblf 43z- In.vl ti1.ANUFACTURI�R `1 Iufid1115; eI[c ;31�a1[besufI 433. fora raf a = t l F{ 0�j s� �� #� COYIFARTIvIIxfaLIZLI�rnN DATE INSTAL D �} K Yes Na 434` 435. TAMCCAYAC if"Yes,"r 1mi one Rego i e.6 wnvmTlmnt. (YEARJ[vip) TI'IN GALLONS 436 NUMBER OF C0A4p.k R,TMFN-rS (,life j 037 ADDITIONAL D SCRIPTION(I'ar lacni eretonly} W lj m 3i 41 TANK IJSE 439. RotEUNI rare = r ' L MOTOR vEl,frcLE FUEL [Pelhec ,Ta. REGULAR UNLEADED ❑2. LEADED 440 I c<e;1ae Pckol�umTrPe) [3 I13, PREMIUM UNI-11i 4DED ❑5. JET FUEL ❑ 2. NON•FTIEL PETROLEUM ❑3_ DIESEL [36 AVIATION GAS ❑]c. MIDGI ADE UNLEADED ❑ 3. CHEMICAL PRObC1CT ❑4. C:ASOHOL ❑99.OTHER: _ COMMONNAME(11omHsaardaus�NaeenasirveooryPa�1 441.ECAH © d. HAdat) IUS WASTE (*ornHaado-maronahIn intorr e (lncfudes Used Oil) page) 442. ❑ 95 UNKNOWN _ VA Leoillilj 777777 f YPE OF TANK lti C les 3 ❑1 SI*G1.E Al ALL II (Cheek ane ilem only ❑3 SINGLE lM1'AL, h ITII F,3IFERIOR ❑5, SINGLE WALL WITH INTERNAL BLADDER SfY5TFh1" I2 DOU91,E WALL MEMBRANE LINER TAN K MATERIAL- 4• SINGLL WALL IN A VAULT ❑95, U'. SI.\iOWN priinnry; }, BADE STHEL 3. FIBER(eLASS f PLASTIC 99 OTHER iChnckcrercemonly) 02. STAINLESS STEEL S. CONCRETE 091 UNKNOWN 4. STEEL CLAD W/FIBERGLASS 44a. TANK MATERIAL-secc�d lank REINFORCED ❑S, FRP Com?ATUILE ❑99,OTHER: 1e3' 1. BARE STEEL FLRS'1TU.FRP) W;100%METHANOL (Check one item only) 3. FIgERULASS/PLASTIC 5. FRPCOAIPTIBLEW1 QI :ic 02. STAINLESSSTEEL 4. STEEL CLAP WIFIHFRGLASS ❑9. FRYNt)N-COf2RC}DABLE)ACKETOL 93.UNKNOWN 445. REINFORCED PLASTIC(PRP,) ❑10. RF ND I)CTI F.L ❑99,OTHER TANK INTERIOR LINING l.I2UBBLR LINED 3 3. rnNCRETE OR COATING []2.ALKYl� LINED EPDXY LINING 5.GLASS LI NI NG 4. 93 UN-KNOWN, (ChccI un item on] ❑ PHF2VDN.IC LINING []G UNLINED 445 ❑ATE INS ALLED 467 OTHER CpRRUS1ON _ ❑99.OTHER PROTECTION I.MANUFACTUREp CATHQDIC- 3.FlBERCrLA55 REINFORCED PLASTIC 95,UNIiNf�YVN If A 1tc461e _ PROTECTIONrUrICL ❑4.IMPRESSED CL'RRE,�rT 448. DATE;INST,,LLE V 449 S 112 2-SAC[iIFlCIAL ANODE ©99.OTHER SPILL AND0}✓pily) L YrARINSTALLED 450 (Check all flat apply) Q I.SPILL CONTAINMENT TYPE 411.. OVERFIL-PROTECTION P.QI7IPMENT YEAR INSTALLEL, 432, ❑2.DROP TIfHP. �_. -'- ❑1.ALARM Sf RIKhR PL ❑3.FRF SHUT OFF VAL VF ❑?. ATE ❑2.BALL FLOAT _ ❑0.FILILL L TUBE Il Si , C':I' xtalc5V Nl,L1 WALL TANK d 8dr1. 1llernon3mtuig ft igcmn Awl litt _€4. E1aca!a rut}} (Check all chat"PPIY} 433. IF DOU9LE WALL.I'ANK 0 TANK WITII BLADDER 454 131.VISUAL(E1{POSE_D PORTION ONLY) ;CI=eck ane item only) ❑2.AU'TOMATiC TANK GAUICj (ATO) ❑5 MANUAL TANK GAUGNNO(r4-I-G) ❑1.VISUAL(SINGLE WALL IN-VAULT ONLY) ❑6 USE ZONE 9L2,CONTINUOUS INTERSTITIAL MONITORINC3 Q 3. CONTINUOUS ATG 1]7,GROCNDW.�,TF32 ❑4, STATIST'ICALWVENTORY RECONCILIATION ❑S.TANK TESTING ❑3,MANUAL MONITORING (SIR)+BIENNIAL TANK TESTING []99.OTHER ESTIMATED DAM LAST USED(Y'R/111U D,� ES TE84A7 F.D{2UANTITy OF 5E185TASviC'E RFti9AINING b TANK FILLED WITH INERT MATERIAL? 457. gatllam ❑Yes 0 No UPCF hwflwrc-b(IM).1)4 hrtp;I1www.u rtidocs,orz Rev.021/6100 'd XlJd dH Wdb 1 :C gooe, T d .JcJd