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• q6�/ ' 1 UNIFIED PROGRAM CONSOLIDATED FORM TANKS 0 UNDERGROUND STORAGE TANKS -TANK P GE ages 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 A&41 A!a(4/F�,� ❑ 7. PERMANENTLY CLOSED O (Speclryreason) (Sponlytemen) ❑ 8. TANK REMOVED 1 BUSINESS as FACILITY NAMEm DHA- Doing Busiwss As) a FACILITY ID: BIJ��LIT J $51 N6 / LOCATION WITHIN SITE (Opdomp /)% I. TANK DESCRIPTION (A scaled plot lan with the location of the UST stem includin buildings and landmarks shall be submitted to the local age c .) TANK ID # 431. TA��NKf MANUFAC'IU/RI-�E)R)/�•� 433. COMPARTMENTALIZED TANK es ❑ No 434. '\ '� Pr6jlEAW �/�anr %NI" If"Ym;'complete one page rm each compmunem. DATE INSTALLED 435. TANK CAPACITY IN GALLONS a3s. NUMBER OF COMPARTMENTS . ,1 (YEAR/MO)V-cdS/ ` 1. /J/d• ADDITIONAL DESCRIPTION (F. loan use ealy) ase. 4t4 V14 "ss z Joy h w&A- 61eX7- II. TANK CONTENTS TANJC USE 439 PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑ Ia. REGULAR UNLEADED ❑ 2LEADED [15. JET FUEL Ofcheeked. complete Petmleum type) [3 lb. PREMIUM UNLEADED M4-'DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ In. MIDGRADE UNLEADED [14. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMICAL PRODUCT441. mv dous Mn�enalslnvmtmYwBc) 442' COMMON NAME (born Hezmdous Matcnels lnvenmrypaec) CAS#OHazar ❑ 4. HAZARDOUS WASTE Ondmics Used Oil) c' J ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 (Check one item only)MEMBRANE LINER ❑ 95. UNKNOWN Q"2. DOUBLE WALL ❑ 4. SINGLE WALL IN ANAULT [199. OTHER TANK MATERIAL -proem, mnk ❑ I. BARE STEEL FIBERGLASS / PLASTIC ❑ S. CONCRETE ❑ 95. UNKNOWN 444. ,❑�..,, �3. (Check one item only) ❑ 2. STAINLESS STEEL 1y4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTIC FRP W1100% METHANOL TANK MATERIAL -secondary mule ❑ 1. BARE STEEL ❑ 3. FIBERGLASS /PLASTIC ❑ 8. FRP COMPTIBLE W/100%METHANOL ❑ 95. UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL @+STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODABLE JACKET '[199. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING [3-1 RUBBER LINED ❑ 3. EPDXY LIMNG ❑ 5. GLASS LINING [195. UNKNOWN 446. DATE INSTALLED 447. OR COATING [12. ALKYD LINING [14. PHENOLIC LINING ❑ 6. UNLINED [199. OTHER Check one item onl OTHER CORROSION ❑ I. MANUFACTURED CATHODIC ❑ 3. F®ERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14. IMPRESSED CURRENT ❑ 99.OTHER HA licabk ❑ 2. SACRIFICIAL ANODE LED SPILL AND OVERFILL YEAR INSTALLED 450. 'jt1'P 451. OVjsRFILL I� PROTECTION EQ 3. FILL TUBE SHUT STAOFF L VALVE 451. (Check all that apply) ❑ 1. SPILL CONTAINMENT �� /-� [12, BALL FLOAT [14. EXEMPT _ ❑ 2. DROP TUBE 24 [33. STRIKER PLATE OIAA iv. TANK LEAK DETECTION (A description of the monitoring mgmm shall he submitted to the local a ency.) 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) E] 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) IH'!. CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE [13. CONTINUOUS ATG ❑ 7. GROUNDWATER [13. MANUAL MONITORING ❑ 4. 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? 457. gallons ❑ Yes ❑ No UPCF hwfwrc-b (1/99) -1/4 www.unidocs.org Rev. 02/16/00