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UNIFIED PROGRAM CONSOLIDATED FORM <br /> (� TANKS E47!UNDERGROUND STORAGE TANKS-TANK PAGE 1ages per tank) <br /> Page-of <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF 1NFOILMATION ❑ 6.TFMPORARY TANK CLOSURE ala. <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (Check one hcm MIY) ❑ 3.RENEWAL PERMIT ❑ S.TANK REMOVED <br /> (Specify rtason) (Specify rtawo) I. <br /> BUSTNESS/SNAME(Same as FACILITY NAME or DBA-Miss Basi^ms As) 3. FACLLITYID: <br /> 10 431. <br /> LOCATION WITHIN SITE(Olnunall <br /> I.TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmaOrMICS Pha433. 11 ENTALIZED TANK ❑Yessubmitted to the local )❑ No 434. <br /> a2. TANK MANUFACTURER <br /> TANK ID# IF"Yes.^wmpinc oM page for each compMment. <br /> q C 436. NUMBER OF COMPARTMENTS 433. <br /> DATE INSTALLED ass. TANK CAPACITY IN GALLONS <br /> (YEAR/MO) -:1- O 0 W 43s. <br /> ADDITIONAL DESCRIPTJUN(For local-e o^N) <br /> II.TANK CONTENTS <br /> aao. <br /> TANK USE 439, PETROLEUM TYPE <br /> 5. JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL 01a. REGULAR UNLEADED 02. LEADED ❑6 AVIATION GAS <br /> (tfchecke4 cmrylne Pmokum Type) [3 lb. PREMIUM UNLEADED ❑3. DIESEL ❑99.OTHER: <br /> ❑Ic MIDGRADE UNLEADED ❑4. GASOHOL E]99. <br /> ❑ 2. NON-FUEL PETROLEUM 441. CAS#(from Raxard°"s Msc"'is Invemory pose) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (Bom Haamdam Mazaials lnvemory past) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION u3 <br /> TYPE-OFT ANK ❑L SINGLE WALL ❑3' SMEMBRAN�E LL WITH INER EXTERIOR O 95 SINMG WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑2 DOUBLE WALL ❑4. SINGLE W ALL IN A VAULT ❑99. OTf�R 444 <br /> ❑5. CONCRETE ❑95.UNKNOWN <br /> t-k ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 99.OTHER: <br /> TANK MATERIAL-prin�YCLAD 8. FRPCOMPATIBLE ❑ <br /> (Check one hem only) <br /> 02. STAINLESS STEEL ❑4. STEEL <br /> EI IJBI-EE F-A'. CG FRP) ❑ W/100%METHANOL _ <br /> 4a5. <br /> 99.OTHER <br /> TANK MATERIAL-secondary tank O 2 S BLESS STEEL❑4. STEEL CLAD WfF BERGLASS ❑9. FRP NON-ORROD/ABLE JACKET OL Q 95.UNKNO <br /> (Check one item only) REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> 05. CONCRETE N6. DATE INSTALLED 411. <br /> TANK O CR KITING OR LINING 2.ALKYD LINING ❑4.PHENOLS L <br /> IC LIINING ❑6.GUNLSINED G ❑99.oTiff-ROS <br /> Check one item onl ) 448. DATE INSTALLED 449. <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC O 4.IMPRESSED CRETCED PLASTIC 1195-OTHER <br /> PROTECTION PROTECTION 451. <br /> f A licable [I2.SACRIFICIAL ANODE 451, OVERFILL PR ON EQUIPMENT: YEAR IN <br /> SPILL AND OVERFILL YEAR MSTALLED aso. TYPE ❑1 ALARM _❑3.FILL TUBE SHUT OFF VALVE <br /> (Check all that apply) ❑1.SPILL CONTAINMENT ❑2.BALL FLOAT- ❑4.EXEMPT <br /> [12.DROP TUBE <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted to the local agency-) ODER 414. <br /> 4s3. ¢DOUBLE WALL TANK OR TANK WITH BLA <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) 6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> [32. AUTOMATIC TANK GAUGING(ATG) ❑ ❑3 MANUAL MONITORING <br /> [33. CONTINUOUS ASG <br /> ❑7.GROUNDWATER <br /> [14. STATISTICAL.INVENTORY RECONCILIATION ❑s.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING <br /> ❑99. OTHER ., <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE N PLACE 457 <br /> ' - 456. TANK flLLED WITH INERT MATERIAL, <br /> 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING ❑YC5 ❑ No <br /> ESTIMATED DATE LAST USED(YRMO/DyAY) gallons <br /> http:l/www.unidocs.org Rev.02/16/00 <br /> UPCF hwfwre-b(1/99)-1/4 <br />