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ok / UPCF hwfwm-b (1/99) -1/4 www.unidocs.org Rev. 02/16/00 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK G Tw ges per tank) Page _ of_ TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 4. AMENDED PERMIT i1( 5. OF INFORMATION ❑ 6. TEMPORARY TANK CLOS TCH.,ANGE (Chxk.iumonly) ❑ 3. RENEWAL PERMIT -�t afN CL'+s4Nfi7f. ❑ 7. PERMANENTLY CLOSED O SI (Specify rcasan) (Spccifyrzum) ❑ a. TANK REMOVED / BUS SSNAME(s..FACIUTY NAMEWDBA-DoingHminess As) 3. FACILITY ID: O d t .�i41 ;zt MI LOCATION WITHIN SITE (Dppmup _ ZC fid 6ufll,v 8ao3 GfASJ /�T rNCA.sf I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildin and landmarks shall he submitted to the IocaI It) TANK ID # 432 TAyN--rKKA/ MANUFACTURE 433. COMPARTMENTALIZED TANK es ❑ No 434. aPOA e�a ��If"Yc."com1sm.pagef0awhcampatmont. DATE INSTALLED 455. TANK{{{ CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 3 ADDITIONAL DESCRIPTION (Fm Imal me only) C .�" ,,rte 438' .6 -V'D4.L. COAfLry/N /ANNE UL N �Et��SZ IL TANK CONTENTS 7A1J,USE 439. PETROLEUM TYPE 940' 1. MOTOR VEHICLE FUEL❑ l�a. REGULARUNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ifchecked, complete Petroleum type) M -b. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ lc. MIDGRADE UNLEADED [14. GASOHOL ❑ 99. OTHER: COMMON NAME III lfazardous Materials lmeatmy Page) �1' CAS#(6mn HazouamdMawWaInvontory page) 993' ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE (IncWdes Used Dip t� ❑ 95. UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR (:15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check we item only) / MEMBRANE LINER ❑ 95. UNKNOWN 1�2. DOUBLE WALL ❑ 4. SINGLE WALL M A VAULT ❑ 99. OTHER TANKMATERIAL-ptimarytank ❑1. BARE STEEL Ci 3. FIBERGLASS /PLASTIC [15. CONCRETE ❑95. UNKNOWN 444. (Chmk me (ton only) C]2. STAINLESS STEEL gl STEEL CLAD W/FIBERGLASS ❑ S. FRP COMPATIBLE [199. OTHER: REINFORCED PLASTIC RP W/100%METHANOL TANKMATERIAL-secondary tank ❑ 1. BARESTEEL 3. ERGLASS/PLASTIC 8. FRPCOMPTIBLEW/100%METHANOL 9$.UNKNGWN 445. (Check we Item only) 02. STAINLESS STEEL STEEL CLAD W/FBERGLASS ❑9. FRPNON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC (FRP) [110. COATED STEEL [15. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 115. GLASS LINING [195. UNKNOWN 446. DATE INSTALLED M7. OR COATING [12. ALKYD LR- NG ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER Check me item ml OTHER CORROSION 13 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 44d. DATE INSTALLED 499. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT [199. OTHER f Applinable [12. SACRIFICIAL ANODE SPILL AND OVERFILL YEA INSTALLED 450, J�'p,E�a�453. OVWILLPHROTECTTON EQU}P TUBE SHUT OFF VALVE YNCINSTALLED-453 MIZ3 (Check all that apply) SPILL CONTAINMENTrnw rF' R1 BALL FLOAT ❑ 4. EXEMPT . DROP TUBE7- 04,60[12. _ Ali 3. STRIKER PLATE 40:-L- 1V.'1 AIN & LEAK DETECTION (A description of the mmitoring propmshall be submitted to the local agency.) IV DOUBLE WALL TANK OR TANK WITH BLADDER 454. IF SINGLE WALL TANK (Check me item mly) (Check all that apply) ❑ 1. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑ 8. 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? 4n. gallms []Yes ❑ No UPCF hwfwm-b (1/99) -1/4 www.unidocs.org Rev. 02/16/00