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1p UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page 2 of 7 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 (Specifyreason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY ID: Rai Gas Stations,Inc.dba March Lane 76 LOCATION WITHIN SITE(Optional) 431, I.TANK DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433• COMPARTMENTALIZED TANK ❑Yes ® No 434. TA-0117506 XERXES If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 01/01/1991 9728 1 ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL 19 I a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petroleum Type) ❑ lb. PREMIUM UNLEADED [3 3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE Unleaded Gasoline 8006-61-9 (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK U 1. SINGLE WALL El 3. SINGLE WALL WITH EXTERIOR 0 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 C 3. FIBERGLASS/PLASTIC ❑5. CONCRETE L1 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL N 3. FIBERGLASS/PLASTIC LJ 8. FRP COMPTIBLE W/100%METHANOL L1 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING Ll L RUBBER LINED LJ 3.EPDXY LINING Q 5.GLASS LINING U 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION L1 1.MANUFACTURED CATHODIC Ll 3.FIBERGLASS REINFORCED PLASTIC LJ 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (If A hcable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 2003 ❑1.ALARM _®3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2003 [12.BALL FLOAT_❑4.EXEMPT ®3.STRIKER PLATE 1998 IV.TANK LEAK DETECTION (A description ofthe 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) ❑L VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑L VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(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 TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455• ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 451. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 www.unidoes.org Rev.02/16/00