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0 0 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page _ of _ TYPE OF ACTION AaV. NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. (Check am item only) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (specify reason) (specify reamn) S. TANK REMOVED BUSINESS NAME(sa7aa FACBMNAMEor DBA -Doing Baainme Aa) 3. FACILITY ID: 1. M1 -✓d£S IBIS LGA LOCATION WITHIN SITE (opcoml) 431 PO`, G ✓� I. TANK DESCRIPTION CJIJ(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency,) TANK ID # /j 431 �O TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑ Yes No 434. /��((� / ry IE"Yea,"m�Weone page for urh m�ryutmem DA INSTALLED 435. TANK CAPACITY IN GALLONS 43s. NUMBER OF COMPARTMENTS (YEAR/MO) &,j cyahj 433. r/) o(VL ADDITIONAL DESCRIPTION (For local ox only) 431. II. TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED [15. JET FUEL (Ifchec11,4 comylaa Petmkum type) ❑ Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ le. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (Som Bacerdone Materials Inventory page) 441. CAS#(Som Harardam Materials lnvmtory page) 441 ❑ 4. HAZARDOUS WASTE (Includes Used Oi0 95. UNKNOWN III. TANKCONSTRUCTION TYPE OF TANK SINGLE WALL C3 3. SINGLE WALL WITH EXTERIOR El 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER El 95. UNKNOWN 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL -primary tank .BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444. (Check one item only) ❑ 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTICFRP W/100%METHANOL TANK MATERIAL - secondary tank 1. BARE STEEL 3. FIBERGLASS /PLASTIC 8. FRP COMP IBLE W/100% METHANOL ❑ 95. UNKNOWN 445. (Check one item only)_ r ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) [110. COATED STEEL [15. CONCRETE TANK INTERIOR LINING 0 1. RUBBER LINED Lj 3. EPDXY LINING 0 5. GLASS LINING ❑ 95. UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LININGC_6. UNLINED ❑ 99.OTHER Check one item only)`�� OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC [13. FIBERGLASS REINFORCED PLASTIC 5. UNKNOWN 44g. DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99.OTHER IfApplicable) 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that a ly) ❑ 1. SPILL CONTAINMENT [11. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. 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) VLSUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ I. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION [18. TANK TESTING (SIR) + BIENNIAL TANK TESTING ❑ 99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DA' ELAST USED 455 ESTIMATED/ppp�UANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT TERIAL? 457. ((//([�Il�, `J gallons ❑Yes No UPCF hwfwre-b (1/99) -1/4 http://www.unidoes.org Rev. 02/16/00