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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chink one nem only) ❑ 3.RENEWAL PERMIT �❑r�O7�.PERMANENTLY CLOSED ON SITE (Specify reason) (specify reason) 1 -°.TANK REMOVED L BUSINESS NAME(Same as FACII.IIY NAME a DBA-Doing Busines3. FACILITY ID:s As) } 431. LOCATION WIIHIN�S`ITE(OptionaD J1�3 Ls - L TANK DESCRIPTION I' (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local.agency.) TANK IQ,# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434. ZIf"Yes;'complete one page for mb compartment DATE TALLED 106Q LA�433. TANK CAPACITY IN GALLONS °36. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 438. ADDITIONAL DESCRIPTION(For local me only) II.TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchaked, amplere Petmlwm Type) 01b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM [11, MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER: [13. CHEMICALPRODUCT COMMON NAME (from Hmredom Materials lnvemory page) 441 CAS#(from Ha:armas Mmerials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Cbeck one item only) DOUBLE WALL MEMBRANE LINER [195. UNKNOWN ❑2. ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL C:13. FIBERGLASS/PLASTIC ❑S. CONCRETE [195.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRPI W1I0O%METHANOL TANK MATERIAL-secondary tank ❑I. BARE STEEL ❑3. FIBERGLASS/PLASTIC 08. FRPCOMPTIBLE W/lOO%METHANOL 95.UNKNOWN 445, (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199,OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑I.RUBBER LINED El 3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 449. OR COATING [12.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED [199.OTHER Checone k item ovl ) OTHER CORROSION 11 1.MANUFACTURED CATHODIC ED PLASTIC ❑95.UNKNOWN ❑3.FIBERGLASS REINFORC4ag. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER (If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSLLE TAD 450. TYPE 451. OVERFILL PROTECTION EQUIPMEM: YEAR INSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT ❑ 1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE El2.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT [13.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the Ioca1 agency.) 453. IF DOUBLE WA LL TANK OR TANK WITH BLADDER 454. IF SINGLEWALLTANK (Check one item only) (Check all that apply) ❑1. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3,CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE- ESTIMATED DATE LAST USED YR/M0/DAY) 455' ESTIMATED QUAMITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 45z 7 �/ I gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 littp://www.unidoes.org Rev.02/16/00