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U FIED PROGRAM CONSOLIDATED FOPIM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (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 ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) S.TANK REMOVED CN�nlu BUSINESS NAME(Sae as FACILITY NAME or DBA-Wing Business As) J. FACILITY ID: tl'"' 1' t77xwv L^�. 1= 2.063 47 m LOCATION WITHIN SITE(Option) 431. 5,,R. 1'7 I.TANK DESCRIPTION (A scaled plot planwith the location of the OST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes')4 No 434. �J L)/�'kNo..3"} V�K N" If"Yes,"compltte one page for each mmpanment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) �0 9rtLC.ru� AJC V KIGISJ.J ADDITIONAL DESCRIPTION(For meal use only) 438. II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440. a 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifeheeked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL C999.OTHER: bl L-Ve r/K A3 TyPer ❑ 3. CHEMICALPRODUCT COMMON NAME (from Hazardous Materials Inventory page) 461' CAS#(from llvardoue Meterials Inventory page) 442_ ❑ 4. HAZARDOUS WASTE (Includes Used Oil) N V l.J kFaDs.a A] ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL El 3, SINGLE WALL WITH EXTERIOR E]5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 4" (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑B. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank E]1. BARE STEEL El 3. FIBERGLASS/PLASTIC ❑8. FRP COMPfIBLE W/100%METHANOL 095.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED [P 99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 44g. DATE INSTALLED 449, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT �2'99.OTHER ALOA1or If A licable ❑2.SACRIFICIAL ANODE V) )re cv -j SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ❑ 1.SPILL CONTAINMENT ❑ 1.ALARM [13.FILL TUBE SHUT OFF VALVE [:12.DROP TUBE ❑2.BALL FLOAT ❑4.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) ❑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 ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING El 99. OTHER NPr V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 056 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No 4P UPCF hwfwre-b(1/99)-I/4 http://www.unidoes.org Rev.02/16/00