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Y \ , <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PA (Two pages Per MA) <br /> �J� Page hof �- <br /> P 5.CHANGE OF INFORMATION ❑ 6 TEMPORARY TANK CLOSURE 430. <br /> TYPE OF ACf10N ❑ I.NEW PERMIT ❑ 4.AMENDED]PERMIT Y <br /> ❑ 7.PERMANENTL CLOSED ON SITE <br /> (Chsk eve itcm Dict) ❑ 3.RENEWAL PERMIT ❑ S.TANK REMOVED <br /> (spaify mawo) OP.*rta ) 1. <br /> BUSINES1A S ��" <br /> NAME(Seme as FACILITY NAME-VBA-Do-gBusness As) 3. FACILITY[): R d D <br /> LU <br /> A- 'M`AL 431. <br /> LOCATION WIT SITE(oPSond) VO4 <br /> p p F o " H 66 I"K DESCRIPTION <br /> (A scaled plot plan with the location of the UST System including buildings and landmarks shall be submitted to the local agency.) <br /> a3z. TANKMANUFACTURER d33- COMPARTMENTALIZED TANK ❑Yes ® No <br /> 434 <br /> TANK I)H /" if"Ya,"mmvine eve page f-e,m compe`mim,. <br /> (a TA 435. TANK CAPACITY IN GALLONS b 436 NUMBER OF COMPARTMENTS 432. <br /> DATE INSTALLED <br /> (YEAIUMMO) d D A <br /> 438. <br /> h <br /> ADDITIONAL DESC'RIPTTON(F-t-sl vse Doty) <br /> IL TANK CONTENTS <br /> a4o. <br /> TANK USE 439. PETROLEUMTYPE - <br /> 5. JET FUEL1. M070R VFHICI.EFUEL [3la REGULARUNLEADED ❑2' LEADED ESEL ❑6. AVIATION GAS <br /> (I(eh.d.d,4 11de Pevohmm TYPe) 4PIb, PREMIUM UNLEADED <br /> ❑4. <br /> E UNLEADED GASOHOL ❑W.OTIIER 44z <br /> ❑ 2 NON-pUEI,PE7ROLl:UM ❑Ic.hID3GRAD a4t. CA$q(Imm ttsxa.dow t4atminb ln�rnt-r vas) <br /> ❑ 3. CHEjGCAL PRODUCT COMMONNAME (sem oared-sMmaial�s>oT`*'r�a°'y wg`) <br /> ❑ 4. HAZARDOUS WASTE <br /> (1.tldc Used Oil) <br /> ❑ 95.UNKNOWN �- <br /> III TANK CONSTRUCTION7U- INGLE WALL aa3 <br /> TYPE OF TANK ❑1. SINGLE WALL ❑3. b1Q4BRANE LINER EXTERIOR ❑95 SUNKNOtVN WITH INTERNAL BLADDER SYSTEM <br /> i Cbeck one item only) 2.DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER 95.CINIONOWN 414. <br /> TANKMATERIAL-primmy uvk L BARE STEEL 3.FIBERGLASS/PLASTIC 5. CONCRETE <br /> (Chea eve item o41y) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP�COM BTHANOL ❑99.OTt1ER <br /> REINFORCED PLASTIC 445. <br /> TANK MATERIAL-secwdary tank 1. BARE STEEL �3.FIBERGLASS/PLASTIC ❑B.FRP COMP7BIE W/100°/METHANOL ❑95.(1FIKNOWN <br /> ((beck one item only) [12. STAINLESS STEEL❑4. STEEL CLAD R®PLI��(FRP) E]90 FCOATID ORRODABLE JACKET ❑99.OTHER <br /> REINF❑ TEEL <br /> 5. CONCRETE446. DATEINSTALLED MT <br /> OR�TANKR.rIMOR LINING OATING [32.ALKYD/.WING ❑4.PIffNOId•CNINLINIFIG ❑6.GUNLINED ImhiG ❑99.OTHERUNKNOWN <br /> Check Doc item onl 448. DATEINSTALLED 449. <br /> O"lllElt CORROSION ❑I.MANUFACTURID CATHODIC�[Q]34.IMPRESSEDCURRENTCED PLASTIC O 99.OTHER WN <br /> PROTECTION PROTECTION <br /> likable ❑2.SACKMCIAL AN 451. OVERFILL PROTECTION EQIJIPMEN'T: YEAR INSTALLED 452. <br /> SPILL AND OVERFILL YEAR IN57ALI.ED ase. TYPE in a 1.ALARM Oaf.■3.FILL TUBE SHOT OFF VALVE'>-tO <br /> ((beck all that apply) a L SPILL CONTAINMENT O �''""- ❑2.BALL FLOAT_❑4.EXEMPT <br /> ROP TUBE <br /> ®3.)STRIKER PI ATE ✓ � �� <br /> IV.TANK LEAK DETECTION <br /> (A description ofthe monitoring program shall be submitted to the local agency.) 4s4. .. <br /> 4s3. IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLE WALL TANK (Check oneiWta 0n1Y) <br /> ((beck Al that applY) PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL <br /> IN VAULT ONLY) <br /> ❑1. VISUAL(EXPOSED ❑6.VADOSE TONE ❑2.CONTINUOUS UM RSTITTALMONYTORING <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑3.CONTINUOUS ATG <br /> [34. STATISTICAL INVENTORY RECONCILIATION ❑B.TANK TESTING <br /> (SII()+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 4s2. <br /> 455- fiST1MA7ED QUANTITY OF SUBSTANCE REMAINING 455. TANK FILLED WTIHINEtT MATERNL? <br /> F,STIdATID DAZE LAST USED(YR)MO/DAY) PI ❑Yes ❑ No <br />