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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (Twwoo pages per tank) <br /> Page_of <br /> CHANGE OF INFATRON <br /> CLOSURE <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT . O&MO TEMPORARY 6. A <br /> 7.PERMANENTLY CLOSED ON SITE 410. <br /> (Check one kemonlY) El3.RENEWAL PERMIT g,TANK REMOVED <br /> i <br /> (Specify mson) (sPcc frmeann) C] I. <br /> BUSINESS NAME(Sam,.FACILITY NAME or DBA-unme easiness As) ±. FACILITY.CrID(V^`) <br /> 431. <br /> LOCATIO WITHIN SITE(Ovtw a0 <br /> 41 <br /> C I.TANK DESCRIPTION <br /> (A scaled plot pian with the location of the UST system including buildings and S3and pMppRIM submit to the ZED TANK❑Yes)❑ No 434. <br /> TA K ID k 4J2 TANK MANUFACTURER <br /> f If"Yes,"wnWltte one pag<Car each compartment. <br /> /✓ 43sTANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 431, <br /> DATE INSTALLED . >T <br /> (YEAR/M0 �1 <br /> 438, <br /> ADDITIONAL DESCR�TION(For local me only) <br /> If.TANK CONTENTS 440 <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED ❑5. JET FUEL <br /> 6. AVIATION GAS <br /> Ofchecko4 complete PeuoleannTYPO ❑lb. PREMIUM UNLEADED ❑3. DIESEL 6. AVIATION <br /> ❑ 4. GA ❑ q4±. <br /> 2. NON-FUEL PETROLEUM ❑ Ie. MIDGRADE UNLEADED ❑ SOHOL 44L CAS#((rom Hazardous Mazcnals Inventory page) <br /> ❑ 3. CHEMICAL PRODUCT COMMONNAME (from Hanmdom Materials Inventory Page) <br /> ❑ 4, HAZARDOUS WASTE <br /> Ondndes used a0 <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SrNGLEWALL <br /> MEMBRANE LINER EXTERIOR 0 95.SINL WITH UNKNOWN \'l'ER`lAl BLADDER SY &M <br /> ST <br /> (Check one item only) ❑2 DOUBLE W ALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER 4441 <br /> 5. CONCRETE ❑95.UNKNOWN <br /> TANK MATERIAL-primary tank ❑I. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑ ❑99.OTHER: <br /> 8. FRP COMPATIBLE <br /> (Check one item only) ❑2. STAINLESS STEEL [3 4. RREINFORC DPLASTIC FRPL CLAD S ❑ W/100%METHANOL _ WN 4+5 <br /> TANK MATERIAL-secondary tank 03. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET" 99.OTHER <br /> G / <br /> (Check one item only) REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5. CONCRETE 446. DATE INSTALLED 447, <br /> O CR GATING OR LINING 0 2.ALKYD LINING ❑4.P1.7R3ER LINED [13 PHENOLOXY ICLINING [16.GLUNLINED ING ❑99.OTHER WN <br /> Check one item call 448. DATEM ALLED 449_ <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC 0 4.IMPRESSED CLAS CURRENTCED PLASTIC 0 99: THEHER_ <br /> PROTECTION PROTECTION <br /> f A licable ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. b,-AFILLALR?A PROTECTION�� LI TUBE SHUT OFF VALVE ARINSTALLED 6 <br /> (Check all that apply) ❑1.SPILL CONTAINMENT ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> ❑2.DROP TUBE <br /> ❑;.STROCER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be 53brmd to the local ag(MCY-) <br /> ¢DOUBLE WALL TANK OR TANK WITH BLADDER 454, <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) ❑6 MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ON <br /> [3 L VISUAL(EXPOSED PORTION ONLY) ❑6 VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2,AUTOMATIC TANK GAUGING(ATG) ❑7 GROUNDWATER ❑3.MANUAL MONITORING <br /> (:13.CONTINUOUS ATG <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 4$1 <br /> 455. 4�' TANK flLLED WITH INERT MATERIAL' <br /> ESTENATED DATE LAST USED(YRMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE R6MAOQLNG ❑yes ❑ No <br /> 2 gallons <br /> http://www.unidoes.org Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-1/4 <br />