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Adk <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS lj <br /> UNDERGROUND STORAGE TANKS-TANJ� - 3 0 - (T-pages Per tank) <br /> D2 �oDn ����JJ// Pageof-;l <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION O 7.PERMANENT6.TEMPORARY LY CLOSED ON SITE a3o. <br /> (CM1 kwcisw adY) ❑ 3.RENEWAL PERMIT El S.TANK REMOVED <br /> (Sp.*-) (SP�fy rtawo) 1. <br /> BUSINESSNANIE(SameasFACBITYNAMEmDBA-Doing Business As) 3. FACILITY ID: e 6 O Q 'Cl 5' <br /> T O S `I� F "1 431. <br /> LOCATION WIT SITE(Opuooa) c.� ov 5 silo <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with t}ke location ofthe UST system including buildings and landnmrics shall be submitted to the local agency.) <br /> TANK ID N m2. TA�sN�K MANUFACTURER r 433. COMPARTMENTALIZED TANK ❑Yes No 4x. <br /> TA D I I V DO V W LM t✓O IL V ER O one N ro azL o NTS vt. <br /> ATE INSTALLED <br /> 43s. TANKCAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS 437. <br /> (YEAR/MO) \C)0 O v <br /> LILY\Kl 435. <br /> ADDITIONAL DESCRIPTION(F.1-w aseady) <br /> IL TANK CONTENTS <br /> a40. <br /> TANK USE u9. PETROLEUMTYPE <br /> 0 1.MOTOR VEHICLE FUEL a la REGULAR UNLEADED [12. LEADED ❑5. JET FUEL <br /> (Ksh«lnl wmPkm P4aolcssm TSP-) El lb. PREMIUM UNLEADED 03.DIESEL ❑6. AVIATION GAS <br /> ❑ 2- NON-FUEL PETROLEUM ❑Ic.MIDGRADE L1NI.F.ADID ❑4. GASOHOL ❑99-OTHER- <br /> 0 <br /> THER a 2 <br /> 441. CASf!(ram[1am.ams Mani-brn�t«r wb-) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (Sam HaasNous Mztnl'�'1°nm°'Y P-5`) <br /> ❑ 4. HAZARDOUS WASTE <br /> 0.r .Used Oil) <br /> ❑ 95.UNKNOWN - <br /> III.TANK CONSTR CTION <br /> TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WAIL WITHEXTERIOR ❑5. SINGLE WALL W17H INTERNAL BLADDER SYSTEM 443. <br /> T <br /> T PE one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> ®2 DOUBLE WALL ❑4. SINGLE WAIL IN A VAULT ❑99. OTHER d13_ <br /> TANK MATERIAL-p�ma,y soul 1. BARE STEEL 3,FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN <br /> (Cyys S.FRP COMPATIBLE ❑99.OTHER <br /> me nem 0y) [12.STAINLESS STEEL. ❑4. STEEL CLAD W/FTBERGLASS ❑ <br /> REINFORCED PLAST11:1. W/100-AMETHANOL <br /> TANK MATERIAL-seconklary took 1. BARE STEEL 3.FIBERGLASS/PLASTIC ❑8.FRP COIriPI1BLE W/100%METHANOL ❑95.UNKNOWN 445 <br /> ((heck one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBBRGLASS 119 FRP NONCORRODABlE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5. CONCRETE 9 ._ <br /> TANK O CR OATINGOR I-INING ❑2I.RUBBER 3..ALKYD LINING ❑4.EPDX01L1.C41NGNG 06 <br /> �i)NI.A'ED LINING GLASS ❑99.OTHER <br /> WN DATE INSTAL l Ffl 447. <br /> Check one item®1 448_ DATE INSTALLED 449. <br /> OTHER CORROSION ❑I.MANUFACI'URal CATHODIC ❑3.F®ERGLASS REINFORC®PLASTIC OTIiQt WN <br /> PROTECTION PROTECTION ❑4.NPRESSED CURRENT <br /> 'cable ❑2.SACRIFICIAL.ANODE <br /> SPR.L AND OVFREIL O STALLED 450. TYPE 453. WI.AARM fS X I0'2 E 3. LLL TUBE SHUT OFF VALVED 14.03 <br /> (Chedc aR that applY) W 1.SPILL CONTAINMENT -Q ❑2.BALL FLOAT_ [14.EXEMPT <br /> 9 2.DROP TUBE0 3.STRIKER PLATE V' \•0 O P J <br /> IV.TANK LEAK DETECTION <br /> (A description ofthe monitoring program shall be4submilled�BelLTANK local� OR TANK WITH BLADDER 4s <br /> IF SINGLE WALL TANK (Check one item only) <br /> ((hack all that apply) 5.MANUAL TANK GAUGING(MIG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) [3 <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VAl)OSE ZONE <br /> Z.CONTINUOUS INTERSTITIAL MONITORING <br /> [13. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> [14. STATISTICAL nWENTORY RECONC'UATION [18.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRWO/DAY) 455. ESTIMATED QUANTRY OF SUBSTANCE REMAINING 4%. TANK FULLED WRH INERT MATEUAL? <br /> 457. <br /> gallons ❑Yes ❑ No <br />