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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE I (Two pages per tank) Page_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION 0 6.TEMPORARY TANK O 7.PERMANENTLY CLOSES ON CLOSURE ITE 430. (Check one nem only) ❑ 3.RENEWAL PERMIT (Specify reason) (Speclfyrcason) [1 8.TANK REMOVED I. BUSINESS NAME(Sameas FACnATVNAh mDBA-wing&uineas As) 3. FACILITY ID: " t }(o 431. LOCATION WITHIN SITE(Optkna0 Cf I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID N 432. TANK MANUFACTURER 4J3" COMPARTMENTALIZED TANK ❑Yes ❑ No 43a. So If"Yea"enrollee one pollsnme for each onm ant DATE INSTALLED 435. TANK CAPACITY IN GALLONS 636" NUMBER OF COMPARTMENTS 43) (YEAR/MO) 438. ADDITIONAL DESCRIPTION(For kcal ase only) II.TANK CONTENTS' a0. TANK USE439. PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED [12. LEADED [15. JET FUEL (Ifchecked,completa Penukumiype) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om F3azerdous Materials inventory page) 441. CAS#(from Haaardom Materiak Inventory page) ❑ 4. HAZARDOUS WASTE (Incladn Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE W ALL WRH[NTEILNAL BLADDER SYSTEM "3. (Check one itemonly) MEMBRANELINER [195. UNKNOWN ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER au TANK MATER[AL-primary wik ❑I. BARE STEEL ❑3. FBERGLASS/PLASTIC ❑S. CONCRETE ❑95.UNKNOWN (Check one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/yl-ASTIC ❑8. FRP Co MI 1IBLEW/100%METHANOL 095.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING El I.RUBBER LINED ❑3.EPDXY LINING C!5.GLASS LININC!G 95.11NKNOWN 446. DATE INSTALLED ur. OR COATING [12.ALKYD LIMNG ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one item onl OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 09 5.UNKNOWN 44a. DATE INSTALLED "9 - PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER If A licable [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUJPMENf: YEAR INSTALLED 452. (Check all that apply) [11.SPILL CONTAINMENT [11.ALARM [13.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE [12.BALL FLOAT_ ❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be sub. -tt i ed to the local F DOUBLE WALL TANK OR TANK WITH BLADDER 454' IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SUR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSUREIN PLACE 4sr. ESTIMATED DATE LAS USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 3 gallons ❑Yes ❑ No 73� 0 Rev.02116/00 UPCF hwtwrc-b(1/99)-1/4 http://www.unidoc&org