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' 12 UNIFIED PROGRAM CONSOLIDATED FORM z1 TANKS a�oa\1n 1� UNDERGROUND STORAGE TANK K PA E 1 `1 ,al Two pages per tank) 1867 Page of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) 'o3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specifyreason) (specify«smn) ❑ 8.TAN�31K REMOVED BUSINESSNAME(same ae FACILDTNA DBA-Doing easiness As) 3. FACILITY ID: 1 Cl S DD 1 Da LOCATION WITHIN SITE(optional) 431 S ✓ S CO�nl �t 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[D tt +32 TANK M^A'NUF�AC/TURER 433. COMPARTMENTALIZED TANK ❑Yes o 434. U/V�/V if"Yes,"wmpine one Page for eerk mtryenmenc DATE INSTALLED 433. TANK CAPACITY IN GALLONS 436. rMBER OF COMPARTMENTS 417 ADDITIONAL DESCRIPTION(For local we only) 438. II.TANK CONTENTS TANK USE 439, PETROLEUM TYPE ([ ao. ❑ 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If checked,con,lne Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ,;4'-2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (atom Rui ma Material:mwnmry pap) 4i1' CASR(aom lfar dotes Materials inventory page) 442_ ❑ 4. HAZARDOUS US WASTE (Includes Uud Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OFTANK1. SINGLE WALL El3. SINGLE WALL WITH EXTERIOR El 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank BARE STEEL ❑3. FIBERGLASS/PLASTIC EI 5. CONCRETE C1 95.UNKNOWN 444. (checkonehemonly) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank El 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC El 8. FRP COMPIBLE W/100%METHANOL C3 95.UNKNOWN u5. (Check one item only) ❑2. STAINLESS STEEL El4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER / REINFORCED PLASTIC(FRP) [110. COATED STEEL / ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING W.UNLINED ❑99.OTHER�� V/✓,s' rC (Check ane itemord OTHER CORROSION ❑L MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN tee. DATE INSTALLED a9. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER IfA liceble ❑2.SACRIFICIAL ANODE vat k SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑I.SPILL CONTAINMENT ❑1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE C12.BALL FLOAT ❑4.EXEMPT ❑3.STRIKER PLATE 1414 IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑I. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING -(SIR)+BIENNIAL TANK TESTING 099.OTHER �/L V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED R/MO/DAY) 455, ESTIMATED QUANTITY OF SUBSTANCE REMAINING 056• TANK FILLED WITH INER MATERIAL? 411 PROM ❑Yes o UPCF hwBvrc-b(1/99)-1/4 http://w%w.unidoeLorg Rev.02/16/00