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0 UNIFIED PROGRAM CONSOLIDATED FORM �1l TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 t� (Two pages per tank) Page _ of _ �� TYPE OF ACTION Off. NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE eco. (Checkouitemonly) ❑ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify anon) (specify amn) 8. TANK REMOVED BUSINESS NAME (San FACILITY NAME or DBA -Doing Bounett As) 3. FACB.ITY D. L47- ES 0.1/C-5�✓✓�S7a.25' LGc lbbs LOCATION WITHIN SITE (optiow) ql f�✓% I. TANK DESCRIPTION l CJ :J f ° „ scpled lot lan with the location ofthe USTsyste/n including buildings and;landmarks shall be submlttedao the local,agency,) TANK IDN 433. TANK MA-N/UFAC_T)UR�E"R ) 415. COMPARTMENTALIZED TANK ❑ Yes No �`v®cy.�C(/ 434, /Y If'-Ye;"complete one page 6r each wwaromet DA INSTALLED 455. TANK CAPACITY IN GALLONS 436 NUMBER OF Colylp RTMEN_TS (YEAR/M0) _ 1, 417. ( of vL ADDITIONAL DESCRIPTION (For bw uu only) 419. II. TANK CONTENTS TANK USE 419. PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑ In REGULAR UNLEADED440. [12. (.FADED ❑ 3. JET FUEL (1fcheck4 wmPlem Petroleum Typc) ❑ Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM ❑ In. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICALPRODUCT COMMON NAME (6om Hvudom Mat..:.i.Inwnury page) 44" CASN(Bom Hmamdmo Matana1;Inwntorypege ) 443. CI 4. HAZARDOUS WASTE (Include Used Oil) 95. UNKNOWN iI�r �'FSi`'I£��NSTdt�`C-�IqN TYPE OF TANK 1. SMGLE WALL ❑ 3. SINGLE WALL WITHEXTERIOR ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Cheek one item only) MEMBRANE LINER 095. UNKNOWN 2. DOUBLE WALL 4. SMGLE WALL IN A VAULT 99. OTHER TANK MATERIAL -primary tank .BARE STEEL ❑3. FIBERGLASS/PLASTIC 03. CEM❑95. UNKNOWN 444. (Check one item only) 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: TANK MATERIAL -secondary REINFORCED PLABTIC FRP W/100%METHANOL L BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100Ye METHANOL 9 -UNKNOWN (Check one item only) ❑ 2, STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS []9. FRP NON-CORRODABLE JACKET ❑ 99. OTHER 445. REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING OR COATING ❑ , RUBBER LINED 3, EPDXY LINING 0 S. GLASS LINING C1 95. UNKNOWN 446, . ALKYD LINING ❑ 4. PHENOLIC LINMG-.-I�U. UNLINED ❑ 99. OTHER DATE INSTALLED 447, Check one item only)`�� OTHER CORROSION ❑ 1. M UFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ,95. UNKNOWN 44s. DATE INSTALLED 449. PROTECTION PROTECTION ❑ 4. IMPRESSED CURRENT -'o%': OTHER IfA licable 2.5 CRIFICIAL ANODE SPILL AND OVERFILL (Check all But o ly) ❑ 1. SPILL IONTAINMENT YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 453. DRO ❑ 2. DROP BE ❑ 1. ALARM _ ❑ 3, FILL TUBE SHUT OFF VALVE _ p� 3. R PLATE ❑ 2. BALL FLOAT _ ❑ 4. EXEMPT 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 PORTI ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGI NG (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG [17. GROUNDWATER ❑ 3. MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR) + BIENNIAL TANK TE 3171,10 El 99. OTHER V TANKCLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED USED(," R/MO/DAY) 455- ESTIM TED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT TERIAL7 457 -D/At1LAST <L' �r� 4Jf gaItoru ❑ Yes No UPCF hwfwre-b (1/99) -1/4 http://"w.unidocs.org Rev. 02/16/00 �# v oy