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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Pag 77 9- TYPE TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT (K5 CHANGE OF INFORMATION 7PERMANENTLYMRYSIREO SITE SITE (Cheek are item rely) 430 ❑ 3 RENEWAL PERMIT (Bpedryseaeon-tor local use ody) (Spxih aasra-fodoral vee ody) ❑ 6 TANK REMOVED 1 BUSINESS NAME(s.memFACILITY NAME or DBA-Doing Bueincae As) 3 FACILITY ID: '! 431 LOCATION WITHIN SI (opeoam) I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) 43z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes o a3s TANK ID# /J 0M11owe (S ( 0rhfh if-yes-,wmplae one page for cath compamment. DATE STALLED(YEAR/MO) 035 TANK CAPACITY IN GALL S 436 NUMBER OF COMPARTMENTS 437 S/i0 92 20 poo j/ofls �� 63B ADDITIONAL DESCRB'TION(For Iwai we only) II.TANK CONTENTS aro TANK USE 039 PETROLEUM TYPE JK1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED 05. JET FUEL (IfmaheLwmplete Peauleum Type) ❑lb. PREMIUM UNLEADED ,S[3. DIESEL 06. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (arm Havdoua Maariale Iave story page) MI CAS#(_H---Materiahlevrnbry page) 443 ❑4. HAZARDOUS WASTE (brabee,Dsetoa) C'�1S ' 685 76 - 3�F-6 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK I. SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check rue imer only) EXTERIOR MEMBRANE LINER [3 95. UNKNOWN J!�2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATER1. BARE STEEL a3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WIF®ERGLASS ❑8. FRP COMPTIBLE W/100°6 METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-awMery took I. BARE STEEL3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 (check one item rely) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED U 3.EPDXY LINING AS.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check ave item ody) (For local uee Duly) OTHER CORROSION ❑l MANUFACTURED CATHODIC 193 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44g DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item ody) ❑2 SACRIFICIAL ANODE (For IoW use rely) SPILL AND OVERFILL YEAR INSTALLED 4M TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 1992 452 (Check all that apply) 1 SPILL CONTAINMENT ❑1 ALARM QK3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT CK 3 STRIKER PLATE IV.TANK LEAK DETECTION(A deecripuon of the rwaitotiag proposer shall be submitad a also Iwai agency.) IF SINGLE WALL TANK(Chedk all the apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check ore item only) ❑l VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE TONE W CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.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 MATERIA.? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SVVI Form B