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AL <br /> i <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS V � (/rL <br /> EL UNDERGROUND STORAGE TANKS- <br /> TANK 1 <br /> a 3 0 <br /> 3(Two pages Per tank) <br /> RPage I of <br /> TYPE OF ACTION ❑ 1.lO PERMIT ❑ 4.AMENDED PERMIT .CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (Chckoveiunwty) ❑ 3.RENEWAL PERMIT <br /> (SP-Ir-) (SPnorY SCC) ❑ B.TANK REMOVED <br /> I. <br /> BUSINESS NAME(Son,.as FACILITY NA[ or DRA-Doing Buvoess As) 3. FACILITY ID: ^ <br /> •'1 V ( c� 431. <br /> LOCATIO WITHIN ITE(ophoonq G fj q S 3 <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and SCOlandmarks �hall be submitted T_MEHI�IZto the local EDTANK C]Y s)i@No 43a <br /> TANK IDp <br /> TANK MANUFACTURER <br /> DVO� h'�' C,iV2 �k is Y"Ya,"comPMe one PnBo foroch comP��mr. <br /> DATE INSTALLED °35. TANK CAPACITY IN GALLONS <br /> 436. NUMBER OF COMPARTMENTS 43'7. <br /> (YEAR/MO) L <br /> 438, <br /> ADDITIONAL DESCRIPTION(Fortood ox only) <br /> IL TANK CONTENTS <br /> 4ao. <br /> TANK USE 439. PETROLEUMTYPE <br /> I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL <br /> (lfrLatsq comPtete Peookum TyPn) . PRENIIl1M UNLEADED 03.DIESEL ❑ <br /> 6. AVIATION GAS <br /> ❑ 2. NON-FUFL PETROLEUM ❑lc.MJDGRAOE UNLEADED ❑4- GASOHOL ❑99-OTHER: s4z. <br /> at. CAS#(bom Ba>udausAwmahhncnoa P=go) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (boot 11-4-1 Mmc"ts tn"o"'rWg) <br /> ❑ 4. HAZARDOUS WASTE �\ <br /> (l UOil) <br /> 95.11N v <br /> ❑ 95.UNKNOWN (`�= (F�4-`d+•�4n-'�-r�,�' <br /> IIL TANK CONSTRUCTION a3 <br /> TYPE OF TK ❑L SINGLE WALL ❑3' Sb.Q.rIBRANE LINER EXTERIOR 0 95.SUNIU40WN W17'Fl1NTERNAL BLADDER SYSTEM <br /> AN <br /> ((heck one item only) ®2.DOUBLE WALL ❑4. SINGLE WAIL IN A VAULT ❑99. OTHER 95.UNKNOWN 444. <br /> TANKMATSUAL-pmrnm mk 1.BARESTEEL <br /> 3. FIBERGLASS/PLASTIC 5. CONCRETE <br /> (Chckooeh®Doty) MPATIBLE <br /> ❑2. STAINIESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑S.FRP ME7HANDL ❑99.OTHER: <br /> REINFORCED PLASTIC <br /> look ]. BARE STEEL 3. FIBERGLASS/PLASTIC ❑S. FRP CONIP11BLE W/100%METHANOL ❑95.UNKNOWN 445 <br /> TANKMATERIAL-secondary9. . <br /> (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CF�.DWPI GIF P) 0 lOF ABLE JACKET ❑99.OTHER <br /> GATED STEEL <br /> ❑5. CONCRETE 95-UNKNOWNab. DATE INSTALLED 441. <br /> 5.GLASS <br /> O CR OATJI GOR LINING ❑2.ALKYD LINING ❑4.PHENOLIER LlbED [011 C INLIG [16.UNLINED G ❑99.OTHER <br /> Check one item od 44g. DATE INSTALLED 449. <br /> OTHER CORROSION ❑L OC-RED CATHODIC 13.4FTEF RENT PLASTIC O 99 OTHER SOWN <br /> PROTECTION <br /> -Cable ❑2.SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMEI4T: YEAR INSTALLED 452. <br /> SPILL AND OVERFIT t YEAR INSTALLED 450. TYPE 45L ®1.ALARM py,Qj®3.FILLTUBE SHUT OFF VALVE nl <br /> (C�all tbat apply) f 1.SPILL CONTAINbAENT VA-03 - -�" ❑2.BALL FLOAT_ [14.EXEMPT <br /> 192.DROP TUBE <br /> IN 3-STRIKERPI ATE✓ W s IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shallbe submitted to the local agency-) BLADDER 454. <br /> 453- IF DOUBLE WALL TANK OR TANK WITH <br /> IN SINGLE WALL TANK (Check one item only) <br /> (Cheek all that apply) ❑S.MANUAL TANK GAUGING(M7'G) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) <br /> [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 0 2.CONTINUOUS TN ERST IIALMONTTORING <br /> [13 CONTINUOUS ATG <br /> ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> 04. STATISTICALINVENTORYRECONCH"ATION ❑S.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 451 <br /> 415. ESTIMATED QUAN'fT1'Y OF SUBSTANCE REMAINING 456. TANK FILLED <br /> /MWTlTi INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YRO/DAY) gafims 0 Yes 0 No <br />