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IED PROGRAM CONSOLIDATED FORP TANKS _r7+05)Ia UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION W PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one dem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINE§SNAME is.mFACT Af"BA-Do' in sM) 3. FACILITY ID: 1' LOCATION WITHIN SITE(Optumal) 431. I.TANK DESCRIPTION (A scaled plot plan with thelocation of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433, COMPARTMENTALIZED TANK Yes No 434. 7 If"Yes;' on cglete one page for each comineunenL DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436 NUMBEROF COMPARTMENTS 431 (YEAR/MO) ® a u ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TAN USE 439. PETROLEUM TYPE 449, 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) P,,< PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Jr. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICALPRODUCT COMMONNAME (from Hazardous Motefi slnvemorypage) 441' CAS#(from Roetious Materials lnvemny Page) 442_ ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL ❑3. SINGLE W ALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441. (Checkooeitemonly) MEMBRANE LINER ❑95. UNKNOWN . DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-pimary tank 13-1 BARE STEEL Ckr FIBERGLAS-S/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. (Check one hem only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tasdc ❑1. BARE STEEL FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL [15. CONCRETE TANK INTERIOR LINING [1-1.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LIVING ❑95.UNKNOWN 446. DATE INSTALLED 447, OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING [16.UNLINED [199.OTHER Check one item onl OTHER CORROSION [11.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448, DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450, 1 TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) [11.SPILL DROP CONTAINMENT 1.TUBE ❑2.ALARM BALL F OAT ❑4.EXEM[13.FILL E SHUT OFF VALVE PT ❑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 454, (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 CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.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? 451. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-114 www.unidocs.org Rev.02(16/00