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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I\ I (r_Pages per tank) Page _ of TYPE OF ACTION �' 1. NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF MFORMAi[ON ❑ 6. TEMPORARY TANK CLOSURE 430. (Clwckoneimmonly) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify roam.) (specify rearm) 8. TANK REMOVED BUSINESS NAME (BamfuFACILITY NAME or DBA -Doing Business As)3. FACILITY ID: �'«,.}-IT 1. Lt/� £s ®�9K �✓dfS lc�RS' LGL LOCATION WITHIN SITE (opdona) 431. 1. TANI{ DESCRIPTION Scaled lot Ian with the location of the UST system mcludin ,¢uildin and:la4dtRark3 sbalL.tae,submitted:to the local. agency,) K ID # /�� 431 TANK MANUFACTURER 431 COMPARTMENTALIZED TANK ❑ Yes No 434, vKNaw� fry-�mp�..n.p�e�r� nmpnmU IDA INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTSN/MO) 437. ADDITIONAL DESCRIPTION (For ko i. only) 433. II. TANK CONTENTS TANK USE 439. PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED440. ❑ 2. LEADED ❑ 5. JET FUEL Of checked, wmplde Permkum Type) ❑ Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM [Ile. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMIHAZARDAL COMMON NAME (ft.. it.&. hmredals lnveniorypage) 441' CAS#(from Hazardous Muerisls invamry page) 441. ❑ 4. HAZARDOUS WASTE OUS WASTE (hmludc VaM Oi9 95. UNKNOWN 111. TANK CONSTRUCTION' TYPE OF TANK (Check one item only) SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. MEMBRANE LINER C1 95. UNKNOWN 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT99. OTHER TANK MATERIAL-primuy reek Fri, HARE STEEL ❑ 3. FIBERGLASS /PLASTIC ❑ 5, CONCRETE ❑ 95. UNKNOWN 444. (Check... item only) d2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTIC FRP W/I00%METHANOL TANK MATERIAL-sewndary I. BARE STEEL 3. FlBERGLASS/PLASTIC FRP COMPTIBLE W/100% METHANOL 9 -UNKNOWN (Check man item on , ❑ 2. STAINLESS STEEL ❑ 4, STEEL CLAD W/FIBERGLASS [19. FRP NONCORRODABLE JACKET [199. OTHER 445, �f REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING OR COATING ❑ .RUBBER LINED 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN a6. . ALKYD LINING ❑ 4. PHENOLIC UN WG --Q:. UNLINED ❑ 99. OTHER DATE INSTALLED 447. Check om item oN `�� OTHER CORROSION ❑1.M UFACTURED CATHODIC ❑ 3. FIBERGLASS REWFORCID PLASTIC S, UNKNOWN N3. DATEINSTALLED 449. PROTECTION P OTECTION ❑ 4. IMPRESSED CURRENT ❑ .OTHER If A Iicable ❑ 2. S CRIFICIAL ANODE SPILL AND OVERFILL (Che.k Vl M R ply) ❑ L SPILL YEAR INSTALLED 450, NTAINMENT TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. ❑ 2. DRO P DROSTRI BE ❑ 1. ALARM _ ❑ 3. FILL TUBE SHUT OFF VALVE _ �) 3. PLATE C12. BALL FLOAT _ CI 4. EXEMPT IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to thelocal ageno,,, IF SINGLE WALL TANK 4-537 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Chack one item o.ly) VLSUAL(EXPOSED PORTI ONLY) ❑ 5, MANUAL TANK GAUGING(MTG) ❑1. VISUAL (SINGLE WALL W VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUD] IlG (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR) + BIENNIAL TANK TE 3TING 099. OTHER V TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED R/MO/DAY) 455. ESTIMATED ANTITY OF SUBSTANCE REMAINMG 456' TANK FILLED WITH INERT TERIAI,7 457. ��a�_ gallons ❑ Yes No UPCF hwfwrc-b (1/99) -1/4 1http://www.unidocs.org Rev. 02/16/00 01