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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (fwp pages per tank) <br /> Papa _i of _ <br /> T hkok.ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> (Check one item ordy) <br /> ❑3.RENEWAL PERMIT (Speafynaaon-krlacalu» C1 ?. PERMANENTLY CLOSED ON SITE -II� <br /> oMyl (Spaciychupe-krbcal uae only) W& TANKIREMOVED 430 <br /> ELOCAnqN.WTHINSI <br /> SS NAME(Sema as FACILITY NAME or DRA-Doing Business As) FACILITY ID R <br /> i <br /> TE(OpBonalf 431 <br /> l 4x <br /> 1.TANK DESCRIPTION <br /> TANK ID a TANK MANUFACTURER <br /> D� <br /> COMPARTMENTALIZED TANK 11 Yea 11 No <br /> If'Yea'.complete one page fpr septi compartment. <br /> ►�s0 ? <br /> ATE INSTALLED(YEARTANCOMPARTMENTS NUMBER OF <br /> ADDITIONAL DESCRIPTION(F Iocal uu only) <br /> If.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> C9,1. MOTOR VEHICLE FUEL 1:11.. REGULAR UNLEADED 1�h LEADED ❑ 5. JET FUEL <br /> (1I m2. NON-FUEL <br /> ON-F pleb PeorohPETROLEan UM <br /> ❑10. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B.AVIATION FUEL <br /> ❑ 2.CHEMICELPRODUCUM ❑tc MIOGRADEUNLEADED ❑ 4. GASOHOL <br /> ❑ 3.CHEMICAL PRODUCT ❑99. OTHER <br /> ❑ 4, HAZARDOUSWASTE(hec.cea COMMON NAME Qom H➢adIE0p3 Mabnalx lnrenrorypage) LASY(/mm aaN0ed H4Mabnels lnrenfory pope) <br /> Uses Dap <br /> 25 UNKNOWN <br /> LII.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH <br /> ❑ 5. SINGLE WALL NTH INTERNAL BLADDER SYSTEM <br /> (Check ane ibm only) ❑ p, 130UBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT 1199. OTHER <br /> TANK MATERIAL-primary tank 11 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE <br /> 1195 UNKNOWN <br /> (Check oro ibm Dory) ❑ Z. STAINLESS STEEL ❑4, STEELCLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL 0 9. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank 11 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ B. FRP COMPATIBLE W IW%METHANOL 1195. UNKNOWN <br /> (Checkpne Mmpnly, ❑ 2. STAINLESS STEEL ❑ C STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON.CORROOIBLE JACKET 1199.OTHER <br /> REINFORCED PLASTIC(FRP) X10 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING COATING 1111 1. RUBBER LINED 3. EPDXY LINING ❑ 5. GLASS UNING 095. UNKNOWN433 DATEINSTALLED <br /> TA <br /> (CMLk one dem an ) 11 2, ALKYD LINING ❑ 4, PHENOLIC LINING ❑ B. UNLINED 1199. OTHER <br /> OTHER CORROSION Forlacal use LED <br /> PROTECTION IF APPLICABLE 13 1. MANUFACTUR��THODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATEINSTALLEDPROTECTION ❑ 4. IMPRESBEDCURRENT ❑98. OTHER(CMck onedamonry) ❑ 2. SACRIFICIAL A (Forbcal use onry) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(FOTkcal use oNy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check an fhef appy) 11 1 SPILLCONTAINMENT <br /> ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE_ <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT_ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> -IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all theta IF DOUBLE WALL TANK OR TANK WITH BLApOER(CMck orrc ibmo ): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING NATO) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING 1399. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YMAOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> pallpm ❑ <br /> Yes ❑N <br /> CUPAFORM(4/98) FOrmerty SVVRCB Form B <br />