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UNIFIED PROGRAM CONSOLIDATED FORM Q <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages p tank) <br /> Page_of <br /> 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ ❑,�./7�.PERMANENTLY CLOSED ON SITE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT {�.TANK REMOVED <br /> (spoeify reason) (Spo6fyreasw) I_ <br /> 3. FACILITY <br /> BUSINESSNAME(Sm .FFAACI _�Z(� DBA-Dkg Business As) <br /> 'J � 431. <br /> LOCATION WITHIN SITE(Opdnnap <br /> ,.'I AiN&DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarrMPhha11�ENTALIZED TANK []Yeto the local s ❑ No 434. <br /> TANK ID# 42 TANK MANUFACTURER <br /> GH"Y<s,"wmplac one pagc for each companmcnt. <br /> DATE INSTALLED <br /> a3s. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. <br /> (YEAR/MO) <br /> 438. <br /> ADDITIONAL DESCRIPTION(For local ose only) <br /> II.TANK CONTENTS <br /> 440. <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL <br /> (Ifchecked,vonglne Petmlrnm Type) ❑lb. PREMIUM UNLEADED [3 3. DIESEL ❑ <br /> 6. AVIATION GAS <br /> [3 2. <br /> GASOHOL ❑99.OTHER: <br /> 2. NON-FUEL PETROLEUM ❑It. MIDGRADE UNLEADED ❑ 442. <br /> 441. CA$#(from Hazardous Mazeriab lvvrntory page) <br /> ❑ 3. CHEMICALPRODUCT COMMON NAME (from H..&-Matenah Inventory Pag<) <br /> ❑ 4. HAZARDOUSWASTE <br /> (Includes Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION'TY443_ <br /> PE OF TANK ❑1. SINGLE WLL A ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) MEMBRANE LINER [195. UNKNOWN <br /> ❑ LL ❑4. S <br /> 2. IR71 E WALL WALL INA VAULT D9 9' <br /> 99. ❑95.UNKNOWN <br /> OTHER a44 <br /> TANK MATERIAL-prinmry tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑S. CONCRETE FRP COMPATIBLE [D99.OTHER: <br /> (Check one m iteonly) 02. STAINLESS STEEL [14.. STEEL CLAD W/FIBERGASS ❑8, W/100 METHANOL <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-secondary tank ❑l. BARE STEEL [13. FIBERGLASS/PLASTIC ❑s. FRPCOMPTIBLEW/100°/.METHANOL 095.UNKNOWN "5, <br /> (Check one item only) [12. STAINLESS STEEL❑4. REINFI <br /> CLAD REINFORCED PLASTIC ❑ COATEDS IC(FRP) 10. ODABLE JACKET [199.OTHER <br /> COATED STEEL <br /> [15. CONCRETE <br /> TANK INTERIOR LINING ❑2.RpL�ICYD LINING [14.PFIBNOLICC LINING ❑6.GUNLINED LASS LINING ❑99.OTHER WN 446. DATE INSTALLED 447. <br /> OR COATING ❑ <br /> Check one item not ) <br /> OTHER COTIRROSION ❑1.MANUFACTURED CATHODIC ❑❑ OtPItESSED CURRENT <br /> 4.FvIBCED PLASTIC O 99.OTHER 448. s. DATE INSTAL <br /> PROTECON PROTECTION <br /> If A licable ❑2.SACRIFICIAL ANODE <br /> ALLED 450. TYPE 451. O❑VERFIL1. )ALR� ❑13. <br /> ROTECTION I3FI L TUBE SHUT OFF VALVE a <br /> 52. <br /> SPILL AND OVERFILL YEARINST <br /> (Check all that apply) O 1.2.SPILL CONTAINMENT ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> DROP <br /> [13.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the ftwnitoringprogram shall besubmitted <br /> IF WALL TANK OR TANK WITH BLADDER 450 <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) 5 MANUAL ypp7g GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) ❑ 2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑ MANUAL MONITORING <br /> ❑ 3 3. CONTINUOUS ATG ❑7.GROUNDWATER ❑ <br /> [3 4. STATISTICAL INVENTORY RECONCILIATION S.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION:/ PERMANENT CLOSURE IN PLACE 45 <br /> 455. <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 456. TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST SED(YR/MO/DAY) _� gallons ❑Yes ❑ No <br /> 7 3i v 3 <br /> -�-j3()o5 Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org <br />