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UNIFIED PROGRAM CONSOLIDATED FORM g <br />2N rL TANKS <br />UNDERGROUND STORAGE TANKS - TANk PA E 1 <br />(two Pages per tank) <br />J Py. _.f _ <br />TYPE OF ACTION�.LNEW SITE PERMIT ❑ 0 AMENDED PERMIT C15 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br />(CMsku ;unmly) P ❑ 7 PERMANENTLY CLOSED ON SITE <br />❑ 3 RENEWAL PERMIT (Spm0ymum -rwb ummIy) (Sp fymmw-fml.e aNy) ❑ 6 TANKRFMOVED 430 <br />BUSINESS NAMEE(Sw m FACILITY NAME. <br />FACILITY ID:1 <br />TV <br />3 <br />LOCATION WITHIN SITE (Opuom) <br />OI <br />Q S 7- <br />1. TANK DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmark, shall be submitted to the Iota agency.) <br />TANK ID M 455 <br />TANK MANUF Cllr a5S <br />COMPARTMENTALIZED TANK Ye No .S. <br />�� <br />�-vf/ <br />B'Y--.mepl.m-M.fwu �. <br />DATE INSTALLED (YEAR/MO) 455 <br />TANK CAPACITY IN QOQNS 4S6 <br />NUMBER OF CO TMENTS 437 <br />` <br />�Lll//77 L <br />ADDITI AL DESCRIPTION IF- u..l a.. ody) <br />452 <br />II. TANK CONTENTS <br />TANK USE 459 <br />PETROLEUM TYPE -"- <br />�^ <br />I. MOT OR VEHICLE FUEL <br />❑ Is. REGULAR UNLEADED C3 2. LEADED ❑S. JET FUEL <br />0rwvtd.e.W.w v...u.m Typ) <br />❑ Ib. PREMIUM UNLEADED DIESEL [16. AVIATION FUEL <br />❑ 2. NON -FUEL PETROLEUM <br />❑ le. MIDGRADE UNLEADED ❑ 4. GASOHOL [199. OTHER <br />❑ 3. CHEMICAL PRODUCT <br />COMMON NAME (fi.m xuumw M.tevb m YL°1O1y'P'a`) MI <br />CASM(6.w H2u.dou. M.wi.L l.vmwyp <br />❑ 4. HAZARDOUS WASTE <br />DI I. Umd OiB <br />- <br />❑ 95. UNKNOWN <br />C (' L <br />111. TANK CONSTRUCTION <br />TYPE OF TANK SINGLE WALL U 3, SINGLE WALL WITH U5. SINOLEWALLWITHINTERNALBLADDERSYSTEM 445 <br />ICMck.n.Im Wy) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN <br />❑ 2. _ DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER <br />TANK MATERIAL-p^w.0'u.t ARE STEEL 3. FIBERGLASS/PLASTIC 3. CONCRETE 95. UNKNOWN 444 <br />(CMck om im..ly) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100`%METHANOL O 99. OTHER <br />REINFORCED PLASTIC (FRP) <br />TANKMATERIAL-..m.4eyuak I. BARE STEEL 3. FIBERGLASS /PLASTIC S. CONCRETE <br />95. UNKNOWN NS <br />(C Ck... n u y) I ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS C) 8. FRP COMPTIBLE W1100% METHANOL ❑ 99. OTHER <br />/` / REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL <br />fff"'��r/// 13 $, CONCRETE <br />ERIOR L ING I. RUBBER LINED J. EPDXY LINING S. GLASS LINING 93. UNKNOWN Nb DATE INSTALLED w7 <br />ING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING <br />m.xy) ❑bUM.INED ❑99 OTHER <br />(iw IwJ um only) <br />F:: <br />ER CORROSION ❑ 1 MANUFACTURED CATHOD C ❑ 3 FIBERGLASS REINFORCED PLASTIC KNOWN 4u DATE INSTALLED 449 <br />�Q41,J <br />ECIONIFAPPLICAt <br />ION {/ ❑ I IMPRESSED CURRENT ❑99 OTHER <br />wu "Ir, IA L ANODE '/ <br />6w 5.N m. oely) <br />SPILL AND OVERFILLALLED 45o TYPE Oowl um e.h) 451OVERFILL PROTECTION EQUIPMENT:YEAR INSTAL LED <br />452 <br />❑ 1 SENT❑ <br />1 ALARM ❑ 3 FILL TUBE SHUT OFF VALVE <br />❑ 2 <br />❑ 2 BALL FLOAT ❑ 4 EXEMPT <br />❑ 3 SE / V <br />1 V. TANK LEAK DETECTION (A u;p0w, or.1u.um;md.s <br />aw <br />la.s�ma w1I x wbm;rod k, Yu 1w.1 .2e.cy.) <br />IFSINGLE WALL TANK ItSect.n 1hu.pp1y5 451 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br />❑ 1 VISUAL (EXPOSED PORTION ONLY)( <br />❑SMANUAL TANK GAUGING (MTG) <br />kO"0 O"h) <br />❑ I VISUAL(SINGLE WALL IN VAULT ONLY) <br />❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE <br />❑ 2 CONTINUOUS INTERSTITIAL MONITORING <br />❑ 3 CONTINUOUS ATO ❑ 7 GROUNDWATER <br />❑ 3 MANUAL MONITORING <br />❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING <br />(SIR) BIENNIAL TANK TESTING ❑99 OTHER <br />IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE <br />ESTIMATED DATE LAST USED(YR/MO/DAY) 45s <br />ESTIMATED QUANU OF SU TANCE REMAINING 436 <br />I �y <br />TANK FILLED WITH IN TERLAL? 457 <br />U� <br />8 allom <br />❑Yes No <br />UPCF (12/99 revised) 10 Formerly SVrRCB Form B <br />