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UNIFIED PRO ONSOLIDA D FORMgt Jre <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TAN 1 l <br /> (Two pages per tank) <br /> TYPE ACTION NEW PERMIT ❑ 4.AMENDED PERMIT Page-4ofL <br /> ❑ 5.CHANGE OF INFORMATION <br /> (Chink one <br /> item oN ❑ 6.TEMPORARY TANK CLOSURE a0. <br /> Y) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (spttify rmmn) (specify ream) ❑ S.TANK REMOVED <br /> BU,yESS NAME(a.to FACILITY N or DBA-Dom B me 3. FACILITY ll): <br /> �S "' .: <br /> L CATION THIN SITE(Optional) <br /> I.TANK DESCRIPTION <br /> (Ascaledlot lan with the,l <br /> TANK IDocptionof.the USTsystoJninclydingbuddm andlandmsrksshall,besubR(itted•tU,tl}e ig4al;a en, :) <br /> N <Sz TANK MANUFACTURER a33. COMPARTMENTALIZED TANK Lj Yes o <br /> aj� 45a. <br /> DATEINSTALLED 455. Ir•'Yas,^maples.one p.ge a.cock amp.nmeu <br /> TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS <br /> (YEAR/MO) <br /> ADDITIONAL DESCRll'ITON(For local one only) /) O..j 437. <br /> 438. <br /> TANK USE 439. PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 440. <br /> ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (I[eherked,mmpine Permkum TYPe) ❑Ib. PREMIUM UNLEADED 03. DIESEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑ ❑6. AVIATION GAS <br /> Ic. MH)GRADE UNLEADED ❑4, GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om Hazvdous Matedals lnvmro 441• <br /> ❑ 4. HAZARDOUS WASTE wPste) CASN(6om Hazardous Material:Inventory pqe) 442. <br /> (Includes Umel Oil) <br /> 95.UNKNOWN <br /> TIZ IC<CkLSTTGTOl <br /> TYPEOFTANK L SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR - <br /> (Checkoneikmonly) MEMBRANE LIN ER ❑5. SMGLEWALL WITH INTERNAL BLADDER SYSTEM - 443. <br /> ❑2. DOUBLE WALL 4. SMGLE WALL IN A VAULT ❑95. UNKNOWN <br /> TANK MATERIAL_Prior, k . B 99. OTHER <br /> ARE STEEL ❑3. FIBERGLASS/PLASTIC 5. CONCRETE ❑95.UNKNOWN <br /> (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ 444. <br /> ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> TANK MATERIAL-secondary mNc 1. BARE STEEL . FIBERGLAD PLASTIC SS/ <br /> FRP W/i00Y.METHANOL <br /> 3. FIBERGLASS/PLASTICS. FRP COMPfIBLE W/100%METHANOL 95.UNKNOWN a5. <br /> (Check one item only) STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET <br /> ❑99.OTHER <br /> REINFORCED PLASTIC <br /> ❑5. CONCRETE ) ❑10. COATED STEEL <br /> TANK INTERIOR LINING }.RUBBER LINED 3.EPDXY LINING 0 5,GLASS LINING ,s5.UNKNOWN 446. DATE INSTALLED 4a. <br /> OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ��.�q�.r�t�WNED <br /> Chttk one item od per-"'•• 199.OTHER <br /> OTHER CORROSION ❑L MANUFACTURED CATHODIC U 3.FIBERGLASS REINFORCED PLAST[ .UNKNOWN 448. DATE INSTALLED 449. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT El 99.OTHER IfA licable 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. <br /> (Check NI flat apply) ❑1.SPILL CONTAINMENT ❑1 ALARM <br /> ❑2.DROP TUBE i ❑3.FILL TUBE SH FF VALVE <br /> 3.STRIKER PLATE ,.. !V ❑2.BALL FLOAT_ ❑4.EXEM �J <br /> IV.TANK LEAK DETEC�#TON /T <br /> (A dacrip,tign of themonitoringprogram shall be sub ni(ted to ESclocal agency). <br /> IF SINGLE WALL TANK . IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> (Ch all that apply) '53' 454. <br /> -151-VISUAL(EXPOSED PORTION ONLY) IJMTG( ) ❑L 5.MANUAL TANK GAUGING (Check one item INE <br /> VISUAL(SINGLE WALL M VAULT ONLY) <br /> [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG ❑7.GROUNDWATER <br /> ❑3.MANUAL MONITORING <br /> ❑1.STATISTICAL INVENTORY RECONCILIATION ❑6.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099. OTHER <br /> U.TANI{CLOSURE INFORKATION I P.,' - fAA1J.VITT�L>MLLItE IN PLACE <br /> ESTIMATED DATE LAST.^SED R)MO/DAY) 455. ESTIMATHD QU (TY OF SUBSTANCE REMAINING 436 TANK FILLED WITH INERT TERIAL7 457 <br /> U�V gallons Cl Yes tp,No <br /> UPCF hwfwre-h(1/99)-1/4 http://www.unidoes.org Rev.02/16/00 <br />