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IED PROGRAM CONSOLIDATED FO L �j l08 37 TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION .NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430, (Check one dem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify sensor) (Specifyreazon) ❑ 8.TANK REMOVED BUSINESS NAMES.as FACILITY NkME or DBA- ing Business As) 3, FACILITY ID: 1. LOCATION WZ1nN SITE(Optimal) 431, I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agent .) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK es ❑ No 4M. IIf"Yes,"complete one page for eachconpsurchu t. DATE INSTALLED 435. TANK CAPACITY©©LONS 436. NUMBER OF COMPARTMENTS 637 (YEAR/MO) ID ADDITIONAL DESCRIPTION(For local use only) r 438. II.TANK CONTENTS TANKJISE 439, PETROLEUM TYPE 440, 1.1"6 1T MOTOR VEHICLE FUEL ;;.� , REGULAR UNLEADED ❑2. LEADED ❑5. SET FUEL (Ifchecked,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMONNAME (from Hawdoas Materials Inventory page) 441' CAS#(6om Hasardoma Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2 DOUBLE WALL ❑4. INGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary mull, 01. BARE STEEL . FIBERGLASS/PLASTIC ❑5. CONCRETE 095.UNKNOWN 444. (Check one hem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑ 1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199,OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95,UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 44g. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER If Applicable) [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) [11.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE [12.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.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 4M. (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑ 1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE PR.C NTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455_ ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457' gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 www.unidocs.org Rev.02/16/00