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D PROGRAM CONSOLIDATED FO D TANKS UNDERGROUND STORAGE TANKS - TANK pag�0 (Two es per tank) Page_of TYPE OF ACTION ❑ L 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,moon) (Specify reason) ® 8.TANK REMOVED FACILITY ID: Ila I. BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business Aa) 3. „ e's BENNY PROPERTY T 431. LOCATION WITHIN SITE(optional) SOUTHWEST CORNER NEAR SIDEWALK 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. UST-IUNKNOWN15 / S' UNKNOWIf"Yes;'completeone pageforeach compartment DATE INSTALL435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR(MO) UNKNOWN -500 ONE 438_ ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS' TANK USE 439. PETROLEUM TYPE 4i0 ❑ 1. MOTOR VEHICLE FUEL ❑is. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Irehecked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED El 3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazmdons Materials lnventorY Page) 441' CAS#(from Hazardous Mawdalslnventorypage) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) E 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ® I. SINGLG WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443, (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANKMATERIAL-primary tank ®1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑S. CONCRETE 095.UNKNOWN 444. (Check one item only) C]2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 08. FRP COMPATIBLE El 99.OTHER: REINFORCED PLASTIC FRP W/]flit%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. PRP COMPTIBLE W/100%METHANOL ❑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 ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ®95.UNKNOWN 4a6. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED [199.OTHER Check one item onl OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ®95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER IfA licable [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450, TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑ 1.SPILL CONTAINMENT ❑ 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT [14.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 451 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4$0 (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) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING El 99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING ase. TANK FILLED WITH INERT MATERIAL? 57 UNKNOWN 115)1, _EMPTY -'a- gallons ❑Yes ® No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00