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R UNIFIED PROGRAM CONSOLIDATED FORM TANKS 4 / UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages per tank) Page _ of_ TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 4. AMENDED PERMIT 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3. RENEWAL PERMIT 4&74) 1164Lt/HL- ❑ 7. PERMANENTLY CLOSED ON SITE (Sped%reason) (specify..) ❑ 8. TANK REMOVED BUSINESS NAME (S. en FACILITY NAME or DBA -Doing Business As) 3. FACILITY ID: I' �'• z s'N Q 6 LOCATION WITHIN SITE (00ora0` 431. 64 S.o� 703 ot%7 i{' u�� x £'.l k�villiv I. ANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agene .) TANK m # 432. E 433. TANK MANUFACTURER COMPARTMENTALIZED TANK es El NO 434. a a /I A46 '-W wA if .-Ye".. complete one Page for each o.nnP .. DATE INSTALLED 435. TANK CAPACITY IN GALL S 436. NUMBER OF COMPARTMENTS 437 (YEAR'MO) S 3 Ned • 0-401dQ ADDITIONAL DESCRIPTION IF" local ns'm'y)438. .Joa [e w#t- Gr d?_�ew-q4A-f GwtM--,-ate. v1 ,5,f --7 z II. TANK CONTENTS TAN USE 439. PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑ Ia. REGULAR UNLEADED ❑ 2LEADED El 5, !ET FUEL (I checked, complele Petroleum Type) ❑ Ib. PREMIUM UNLEADED We/DIESEL El 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ In. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from tt000doua Materials Inventory case) 441' CAS#(ft=Flnzadous Mamalslnvennnypaee) 442 ❑ 4. HAZARDOUS WASTE QncluJesllsed0il) Ji I6JE� � > ee , J roO7 ✓ T W ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only)MEMBRANE LINER ❑ 95. UNKNOWN 22. DOUBLE WALL ❑ 4. SINGLE WALL M A VAULT El 99. OTHER TANK MATERIAL - primary tank ❑I. BARE STEEL ❑3. FIBERGLASS/ PLASTIC ❑5. CONCRETE 095. UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL 2/4. STEEL CLAD W/FIBERGLASS ❑8. PEP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100% METHANOL TANK MATERIAL -secondary unk [11. BARE STEEL El 3. FIBERGLASS/ PLASTIC ❑8. FRP COMPTIBLE W1100% METHANOL 95. UNKNOWN 445. (Check one I= only) ❑ 2. STAINLESS STEEL bPI�STEEL CLAD W/FIBERGLASS ❑ 9. PRP NON-CORRODABLE JACKET -❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING [11. RUBBER LINED [13. EPDXY LINING ❑ S. GLASS LINING [:195. UNKNOWN 446. DATE INSTALLED "T. OR COATING [12. ALKYD LINING [14. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER Check me item wl OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC [13. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 44d. DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT [199. OTHER If Applicable) [12. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450 'j�'PE 451 NURFILL PROTECTION EQ ENT: YEAR INSTALLED 452. Cr3. FILL TUBE SHUT OFF VALVE (Check all that apply) ❑ 1. SPILL CONTAINMENT �7 � I. ALARM ❑ 2. DROP TUBE y� 'j Lf OW ❑ 2. BALL FLOAT [14. EXEMPT ❑ 3. STRIKER PLATE 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) [11. VISUAL (EXPOSED PORTION ONLY) [15. MANUAL TANK GAUGING (MTG) ❑❑ 1, VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE &-f CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑ S. TANK TESTING (SIR)+ BIENNIAL TANK TESTING 099. 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? 457' gallons ❑Yes ❑ No UPCF hwlWre-b (1/99) -1/4 www.unidocs.org Rev. 02/16/00