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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) <br /> Page_of <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION O &7.PES�TLYANK CLOSED UR SITE a3o <br /> (Check one hem only) ❑ 3.RENEWAL PERMIT _ 8.TANK REMOVED <br /> (BpKify mean^) (specify...) I. <br /> 3. FACILITY ID: "`4' <br /> BUSINESS NAME(Same to FACILITY NAME or DBA-Doing Business As) <br /> - a;. <br /> 431. <br /> LOCATION WITHIN SITE(Optional) i/�y �'� Z J 1 `-n <br /> 1 I.TANK DESCRIPTION <br /> (A scaled plot plan with the lecationpf the UST system including bmldmgs and 3andmaOrl Ph�aI1 ENTALIZED TANKto the ma <br /> I Mal ❑Yes)❑ No 434. <br /> TANK ID N 432 TANK MANUFACTURER <br /> 5 �S H"Yes,"com,lete one page for each conpanment. <br /> DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 4J2. <br /> (YEAR/MO) <br /> 438 <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> H.TANK CONTENTS <br /> "0. <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED El 5. JET FUEL <br /> (Kcheckeetcomplete Petroleum Type) El lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> 441. CAS#(8'om Hazardous Materials Inventory page) 442. <br /> [13. CHEMICAL PRODUCT COMMON NAME (Gom Hazardous Mammal:Invcmory page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Include Used Oil) <br /> ❑ 95.UNKNOWN <br /> SII.TANK CONSTRUCTION <br /> TYPE OF TANK El I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE W ALL WITH INTERNAL BLADDER SYSTEM 443_ <br /> (Check one item only) MEMBRANE LINER [195. UNKNOWN <br /> ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MAT AL tank ❑I. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑S. CONCRETE ❑95.UNKNOWN 494 <br /> (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER:REINFORCED PLASTIC FRP W/100%METHANOL <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑8. FRP COMPTBLE W/100/.METHANOL 095.UNKNOWN 445. <br /> ° <br /> (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD WIFIBERGLASS PLASTIC(FRP) ❑9.FRONTRP ON-STEEL JACKET E]99.OTHER <br /> REIF[15. CONCRETE <br /> TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED a47. <br /> OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING [16.UNLINED ❑99.OTHER <br /> Check one item onl ) UNKN <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC 03 3.FIBERGLASS REINFORCED PLASTIC ❑95.OTHER <br /> PROTECTION PROTECTION ❑4. WN aag. DATEINSTALLED 44 <br /> IMPRESSED CURRENT ❑99.OTHER <br /> It A licable [12.SACRIFICIAL ANODE <br /> $PILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED a52. <br /> (Check It, <br /> apply) ❑1.SPILL CONTAINMENT p,BA1.ALARM OAT_ ❑4.EXEM0 3.FILL PT <br /> SHUT OFF VALVE <br /> [12.DROP TUBE <br /> ❑3.STRIKER PLATE <br /> IV.TANKLEAK DETECTION <br /> (A description of the monitoring. ogam shall be d to the local agency.) <br /> 53. I DOUBLE WALL TANK OR TANK WITH BLADDER 054 <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) <br /> J-]1. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) ❑ .VISUAL(SINGLE WALL IN VAULT ONLY) <br /> [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING <br /> [14. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 457. <br /> 455. ESTIMATED QOAMITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? <br /> ESTEMATED DATE LA T US (YR/MO/DAY) ❑Yes ❑ Na <br /> 7 / 0. gallons <br /> Rev.02!16/00 <br /> UPCF hwfwrc-b(1/99)-1/4 <br /> http://www.unidocs.org <br />