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UNIFIED PROGRAM CONSOLIDATED FORNMF TANKS UNDERGROUND STORAGE TANKS - TANK PAGE tang) r-�� TYPE OF ACTION 1. NEW PERMIT ❑ 4. AMENDED PERMIT V ' CHANGE OF INFORMATION ❑ 6. TEMPORA430. 7CRE (Cheek one item only) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANE (s,dry reason) (Specify reason) ❑ 8. TANK REM BUS E SNAME($knp�s A Iry HAM DB 'ng Business As) 3. FACILITrY/ID:1 � 1�`'Iyfy LO(_fC1 ATIONC ITH S`h]F��I;�(to1 naq/-/earl /\'' %/!�� a �/♦� `/�� 1431. 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.). TANK ID # 431. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑ Yes ❑ No TA 434. If "Yee," conplem one page for each crosparcmem, DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436..NUMBER OF COMPARTMENTS (YEAR/MO) I LCFllis_" 430. ADDITIONAL DESCRIPTION or beat use ono ft 438. II. TANK CONTENTS TADNC USE 439 PBTI;OLEUM TYPE 1. MOTOR VEHICLE FUEL W_ / 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL 440. (Ifchecked, complac Petroleum Type) ❑ lb. PREMIUM UNLEADED ❑3. DIESEL El 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ 1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Mat (from Haaardoue Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE on TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) 443. MEMBRANE LINER El 95. UNKNOWN DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-pmmrytank ❑LBARE STEEL ❑�/3jj. p�,EBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN (Checkone itemLr Yonly) ❑ 2. STAINLESS STEEL W. STEEL CLAD W/FIBERGLASS ❑ S. PRP COMPATIBLE ❑ 99. OTHER: 444. REINFORCED PLASTICFRP W/100% METHANOL TANK MATERIAL -secondary tank ❑]. BARE S7EEL ❑3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHAN0L 95.UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑ 99. OTHER 445. REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING [15. GLASS LINING ❑ 95. UNKNOWN 446. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING DATE INSTALLED 447. UNLINED ❑ 99. OTHER Check one item only) OTHER CORROSION . MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 448. DATE INSTALLED PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER 449. f Applicable) [12. SACRIFICIAL ANODE SPILL AND OVERFILL �/� YE TALLED 451: (Check all that apply) L7] I�SPILL CONTAINMENT TYPE 45I. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE 452. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT 9'f. 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. yISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE p-OKISTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER [13. MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION [18. TANK TESTING (SIR) + BIENNIAL TANK TESTING ❑ 99. OTHER V. TANK kLOSURE, INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/D 455ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456- TANK FILLED WITH INERT MATERIAL? 457. gallons ❑ Yes ❑ No UPCF hwfwrc-b (1/99) -1/4 http://www.unidocs.org Rev. 02/16/00