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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS �I� b <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages pe tank) <br /> Page_of <br /> 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> ENNnAME <br /> NEW PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> RENEWAL PERMIT _TANK REMOVED <br /> (Specify reason) ISPe"16' <br /> FACIITfYNAMEmDBA-Doing Bminas As) 3. FACI3 � 431. <br /> LOCATION WITHIN SITE(opoonaq <br /> 1. 1 DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and jandmaOrkMsPARTMEN COMPARTMENTALIZED TANK ❑Yesto the local ❑ No 434 <br /> TANKI # 432. 11_55b <br /> /� V"Yes,"cosrgletc one page for each congartmrnt. <br /> 1 n OS 5. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. <br /> DATEINSTALLED <br /> (YEAR/MO) <br /> 438. <br /> ADDITIONAL DESCRIPTION(Far Iwai me omy) <br /> D.TANK CONTENTS <br /> 440. <br /> TANK USE 439, PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑ AVIATION ON GAS <br /> AVIATIIa. REGULAR UNLEADED [12. LEADED L <br /> ❑5. <br /> (If cM1ecke4 wsrtJlne Pd-1-Type) [I lb. PREMIUM UNLEADED ❑3. DIESEL ❑ <br /> ❑ 4. GASOHOL ❑99.OTHER: <br /> 2. NON-FUEL PETROLEUM E]tc. MIDGRADE UNLEADED ❑ 442. <br /> 441. CAS#(from Hazardous Materials Inventory Paee) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazmd"m Materiels Inventory page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (IMludes D9ed DI� <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION "3 <br /> TYPE OF Tl+NK C1 I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL W ITH INTERNAL BLADDER SYSTEM <br /> MEMBRANE LINER [195. UNKNOWN <br /> (Check one item only) ❑2 IbUBLE WALL ❑4. SINGLE WALL INA VAULT <br /> ❑99. OTHER 95 UNKNOWN 444 <br /> TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FB3ERGLA55/PLASTIC El 5. CONCRETE ❑ <br /> 8. FRP COMPATIBLE 99.OTHER: <br /> ❑ <br /> (Cheek one Hem only) [12. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑ W/I00°�METHANOL <br /> REINFORCED PLASTIC FRP) <br /> TANK MATERIAL-secondary tank 02. 3 LESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORROD/ABLE ACKETNOL X99.0 HERS 445. <br /> (Check one item only) REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5. CONCRETE 95.UNKNOWN 446, DATE INSTALLED 447. <br /> O CA OATINGIOR LINING O 2.ALKYD LINING ❑4.PPk�NOLIC LNINING ❑6.GLASSED <br /> ING ❑99.OTHER <br /> Check one item od ) <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑4.FIB <br /> FIESSED CREURNJMCED PLASTIC 0 99.0 HEUNKNR WN 41g. DATEINSTALLED as . <br /> PROTECTION PROTECTION ❑ <br /> LLED 451 <br /> f A licable ❑2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OV <br /> SPILL PROTECTION0 .EQUIPMENT:TBE SHUT OFF VALVE <br /> (Check all that aPPIY) 2.SPILL DROP CONTAINMENT 132.BALL FLOAT_ [14.EXEMPT <br /> ❑3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be453, j:d to the local agency.) <br /> DOUBLE WALL TANK OR TANK WITH BLADDER 450 <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) 5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> C]1.VISUAL(EXPOSED PORTION ONLY) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> [12. AUTOMATIC TANK GAUGING(ATG) ❑T.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑3. CONTINUOUS ATG <br /> [14. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 4sv. <br /> 45s. 456 TANK FILLED WITH INERT MATERIAL' <br /> ESTAIAT DA E LAST USED(YRMO/DAY) ESTIMATW( UANTITY OF SUBSTANCE REMAINING ❑Yes ❑ No <br /> 7 31 03 <br /> Sallow <br /> V�7 - Rev.02/16/00 <br /> GPCF hwBvrc-b(1/99)-1/4 <br /> http://www.unidocs.org <br />