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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 kp11�� (Two pages pa 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 (Specify-w) (Specify,reason) ❑ S.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME m DBA-Doing Baseness As) 3. FACILITY ID: I' RALEY'S FUEL STATION#356 3 LOCATION WITHIN SITE(optional) 431. I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432' TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434. 1XERXES If"Yes,-eon,lete one page r each wmpaswmt. ALL DATE ED 7 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2006/02 TM7 D 1 20,000 1 ADDITIONAL DESCRIPTION(For fowl use only) 438. H.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checko4 complete Petroleum Type) ❑Ib. PREMIUM UNLEADED E]3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haamdoas Materials Inventory page) 441' CAS#(from Ha aod.Materials Jenrette,page) 443. ❑ 4. HAZARDOUS WASTE REGULAR UNLEADED 8006-61-9 (Intludw Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑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 [199. OTHER TANK MATERIAL-primary took ❑1. BARE STEEL N 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN a44. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-sewndary tank E)1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL 095.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LIVING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LR41NG [14.PHENOLIC LINING ®6.UNLINED [199.OTHER (Check one item only) OTHER CORROSION ❑I.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER f Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL INSTALLED 450. TYPE 451. OVERFILL PROTECTIO EQUIPMENT: YEARINSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT _2 PHI.T1TE ®1.ALARM 20f6_ [13.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE 2 6 � PHIL TIfE ®2.BALL FLOAT 06_ ❑4.EXEMPT ®3.STRIKER PLATE 2 6 PHIL TITE 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) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE EST24ATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 457, N/A gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00