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/ UNIFIED PROGRAM CONSOLIDATED FORM TANKS /l ( 3 UNDERGROUND STORAGE TANKS - TANK PAGE 1 ky (Two pages per tank) Page _ of _ TYPE OF ACTION El 1. NEW PERMIT 114. AMENDED PER5�. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430 w ((AerkomiumoNy) ❑ 3. RENEWAL PERMIT /'Gel/ AbJt/Qt ❑ 7. PERMANENTLY CLOSED ON SITE (specify -once.) (Speollyreason) ❑ S. TANK REMOVED BUSINESS NAME (Scene as FACILITY NAME m DBA -Doing Business; As) 1 FACILITY ID: 1' 2 the WGo LOCATION WITHIN SITE (Options]) 431. E�tfT S:aJmd (�u,lfl�w $103 ffa°4f✓A A6 e!e N L TANK DESCRIPTION (A scaled plot plan with the location of the UST "no including buildin and landmarks shall be submitted to the local agency.) TANK ID # 412. TANK MANUFAU IU.sREER 411. COMPARTMENTALIZED TANK es ❑ No 434. IQ E/tA1 ^� a+ 1 N "Ye :' complca ane Pa6e ter aN mnpamnrnr. DATE INSTALLED 415. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (YEAR/MO) ADDITIONAL DESCRIPTION (Far local use only) 438. Avow Wa4,L, Gfesrtogl LQ Csw. zvp I -CNI Ut'-4 N 46S151. II. TANK CONTENTS TANKUSE 439. PETR9LEUMTYPE 440. or 1. MOTOR VEHICLE FUEL l!-Sl/a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL (Ifchecked complete Patrol.. Type) [:I It. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL [:199. OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ft. Hmmdous Materials Inventory page) N1' CAS#(from Hazardous Materials lmen[ory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) �t"reJ`v /' V/ �je'/SOLeNG� pf%O ❑ 95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443, (Check one itemonly) MEMBRANE LINER [195. UNKNOWN 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL -primary lank ❑I. BARE STEEL ❑✓y FIBERGLASS/PLASTIC [3 5. CONCRETE [195. UNKNOWN 444. (Check one item only) [12. STAINLESS STEEL Ltl 4. STEEL CLAD W/FBERGLASS [18. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTIC FRP W/100% METHANOL TANK MATERIAL - secondary lank ❑1. BARE STEEL FIBERGLASS/PLASTIC 08. FRPCOMPTIBLE W/100%METHANOL❑95.UNKNOWN 445. (Check one item only) ❑ 2. STAINLESS STEEL [B 4. STEEL CLAD W/FBERGLASS [19. FRP NON-CORRODABLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ D. GLASS LINING ❑ 95. UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING [16. UNLINED [199. OTHER Check one item ml OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14. IMPRESSED CURRENT [199. OTHER If A licable [12. SACRIFICIAL ANODE SPILL AND OVERFILL YE INSTALLED as0. TY� E�a�d� 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. SHUT OFF VALVE (Check all that apply) ,�,,J/ SPILL CONTAINMENT J 62-u [l�'f. ALARM IX3. FILL TUBE Ids DROP TUBE &PAN ❑ 2. BALL FLOAT _ ❑ 4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION A description of the monitoring ro shall be submitted to the local a eng.) 453, IF DOUBLE WALL TANK OR TANK WITH BLADDER 454, IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ 1. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) [:11. VISUAL (SINGLE WALL IN VAULT ONLY) CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE L72. ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION [18. TANK TESTING (SIR)+ BIENNIAL TANK TESTING ❑99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 45T Pilots ❑ Yes ❑ No UPCF bwfwre-b (1/99) -1/4 www.unidocs.org Rev. 02/16/00