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I <br />UNIFIED PROGRAM CONSOLIDATED FORM 1/ y/oJ <br />Ra UNDERGROUND STORAGE TANKS - TANK PAG FAC B," `x <br />TYPE OF ACTION ❑ INEW SITE PERMIT <br />Km aaA iOn oay) ❑ /AMENDED PERMIT ❑ S CHANGE OF INFORMATION ❑ 6TEMPORARYSITECLOSVRE <br />❑ 3RENEWAL PERMIT ❑ T PERMANENTLY CLOSENDN SRS! <br />BUSINESS N ❑ S TANK REMOVED <br />A(Ba.e. PACILTTT NA6R!vpRA. poen BueYoo,y) FACRJTY ID: <br />THREE PALMS GROCERY PR x: <br />ATI N FSI SITEfOPu..p 6712 E WATRRlt3n 9Try rtn.l FA0004030 PRO231830 �. <br />® L MOTOR VEHICLE FUEL <br />Of I M" NOo4r.TON) <br />❑ 2. NON -FUEL PETROLEUM <br />❑ 3.CKE MICALPRODUCT <br />❑ /. RAZARDGUS WASTE <br />Ochi. U d 00) <br />❑ 95. UNKNOWN <br />432 <br />135 <br />4N- REGULAR UNLEADED <br />❑ Ib.PREMIUMLNLEADED <br />94 19. MIDGRADE UNLEADED <br />❑ 2. LEADED <br />❑ S. DIESEL <br />❑ I. GASOHOL <br />oI <br />436 <br />❑ 5. JET FEEL <br />116. AVIATION FUEL <br />❑ 99.OTHER <br />OFTANK <br />LJ I. SINGLE WALL <br />—_._.•�•••••••,••• a. u6.n <br />❑ 3, SINGLE WALL WITH <br />onmm°M) <br />E <br />EXTERIOR MEMBRANE LINER <br />❑S.SNGLE WAIL WITH INTERNAL BLADDER SYSTEM <br />® 2. DOUBLE WALL <br />/SINGLE WAL <br />❑ L M VAULT <br />❑ 95. UNKNOWN <br />❑ 99 OTHER <br />VO C MATERIAL-POwlY uok <br />= I.BARESTEEL <br />❑ 2. STAINLESS <br />❑ FIBERGLASS I PLASTIC <br />S.CONCRETE ❑ 95.UNKNOWN <br />STEELED❑ <br />STEEL CLAD WGLASS <br />❑ S. FRP COMPTIBLE W1 100% METHANOL <br />' <br />REINFORCED PLASTIC <br />C (FRP) <br />TANK MATERL&L ❑ 99. OTHER <br />�) mlld y mE ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE <br />fC1.Eas Bam ❑ 2. STAINLESS STEEL I4 ❑ 93. UNKNOWN <br />Rs1. STEEL CLAP W/FTBERGLASS 09. FRP COMPTIBLE W/IOfI%MHTHMJOL <br />REINFORCED PLASTIC (FRP) <br />❑ 10. COATED STEEL ❑ 99.OTHPJ( <br />❑ 5. CONCRETE <br />TANK INTERIOR LINING _ :^ <br />OR COATING) ❑ I. RUBBERLNED El 3. EPDXY LNENG ❑ 5, GLASS LINING 095. UNKNOWN 116 DATE NSTAIAJM <br />KLisr <br />❑ Z ALKYD LINING ❑ 1 PHENOLIC LINING ❑ 6 VNLNED ❑ 99, OTHER h: <br />OHIM CORROSION ❑IMANUFACfURINq CATHODIC <br />i PRDTRCAON IF APPLICABLE <br />PROTECTION ❑ 3 FIBERGLASS REINFORCED PLASTICq5 <br />Rl..Am.. y) ❑ I IMPRESSED CURRENT ❑ UNKNOWN W DATEINSTAUZO <br />❑ 2 SACRIFICIAL ANODE ❑ 99OTHER IFj <br />SPBl ANDOVERFR,LYE <br />t% AR MSTALLE59 TYPE IJi OVERFILL PROTECTION EQUIPMENT: YEARBIBTALLED <br />p. fOeY aBya9JNy) ❑ I SPILL CONTAINMENT <br />❑ 1 DROP TUBE ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` _ <br />❑ 3 STRIKER. PLATE ❑ 2 BALL _ ❑ /EXEMPT <br />FLOAT —' <br />IV.?AHK LEAK DETECTION(A e..Wp 6J6...a.eeq.R,.ahoy„�,,,;,�y„uebN ) "° <br />IFSWGLAWALL TANKXU*a ft <br />453 IF DOUBLE WALL TANK OR TANK WITH BLADDER Ift <br />❑ I VISUAL (EXPOSED PORTION ONLY) (F 5 MANUAL TANK GAUGING (MTO)°vben9') . <br />❑2 AUTOMATIC TANK GAUGING (ATG) ❑6VADOSE ZONE ❑ I VISUAL WALL IN VAULT ONLY) <br />❑ 3 CONTINUOUS ATG 00 <br />] GROLNDWATER <br />❑ 1 STATISTICAL INVENTORY RECONCILIATION ❑ B TANK TESTING ® 2 CONTINUOUS INTERSTITLA. MONITORING <br />(SIR) BIENNW. TANK TESTING {] l MANUAL MONITORING <br />❑ " HER <br />V. TANK CIl3RTIRB' <br />ESTIMATED DATE LAST USED(YR/MO/DA bJ F SUBST,.NCEREMIywi <br />Y) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br />i <br />UPCF (12/99 revised) <br />TANK FILLED WITH VERT MATERIAL? <br />❑ Ya ❑ NO <br />