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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page / of L 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 reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACll-ITT NAME or DBA-Doing Busineu As) 1 FACILITY ID: I. DV/ AIA)/C/I-7A L 5rf'f T£ LOCATION WITHIN SITE(optiooa9 T/Z 4)I. I.TANK DESCRIPTION A-scaled lot Ian with the location ofthe UST system includingbuildingsand landmarks shall,be submitted.to the local agency.) TANK ID#3 9'600 LJ/J 3 412 TANK MANUFACTURER [" 433. COMPARTMENTALIZED TANK ❑Yes Z0/33 Z , J T1 If"Yes,"complete one page for each compartment DATE INSTALLED 435. TANK CAPACITY IN GALLONS 476. NUMBER OF COMPARTMENTS (YEAR/MO) 4n ' � 0,90 �/� OAS ADDITIONAL DESCRIPTIONlo (For cal use only) 439. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE I. MOTOR VEHICLE FUEL C3 la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL 440. (If checked,complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED3. DIESEL [12. NON-FUEL PETROLEUM ❑ ❑6. AVIATION GAS ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: as.FD O/L ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials inventory page) 441. CAS#(from Huudous Materials Inventory page) 442. 4. HAZARDOUS WASTE nc udes Used Oil) ❑ 95.UNKNOWN III TA'11K C.ONSTR�`C'�'�ION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITHIN TERNAL BLADDER SYSTEM 443. (Check one item ordy) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. SINGLE WALL 1N A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL E:13. FIBERGLASS/PLASTIC ❑5. CONCRETE EJ 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL �4. STEEL CLAD W/FIBERGLASS C]8. FRP COMPATIBLE C]99.OTHER: REINFORCED PLASTIC ffR.PW/100%METHANOL TANK MATERIAL-secondary tank I. BARE STEEL C3 3. FIBERGLASS/PLASTIC 8. FRP COmi l WLE W/100%METHANOL 0 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 ❑S. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING �Q6.UNLINED ❑99.OTHER Check one item onl /� OTHER CORROSION ❑I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION 13N.IMPRESSED CURRENT ❑99.OTHER If A licable 2.SACRIFICIAL ANODE / p SPILL AND OVERFILL, YEAZINSTALLED 450, TYPE 451. OVERFILL PROTECTION EQ IPMENT: YEAR INSTALLED 452. (Check all that apply) t .SPILL CONTAINMENT AI ARM ❑2.DROP TUBE Z.FILL TUBE SHUT OFF VALVE 3.STRIKER PLATE / Oti.BALL FLOAT_ ❑4.EXEMPT IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 4s4. C3 1. VISUAL(EXPOSED PORTION ONLY (Check one item only) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) [12. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE �2 E]3. CONTINUOUS ATG CONTINUOUS INTERSTITIAL MONITORING ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK'CL•OSURE INFORMATION/ PERIVIANENT'CLOSURE IN P-LACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INE R MATERIAL? 457. gallons ❑Yes No UPCF hwfwrc-b(1/99)-1/4 http://Nvww.unidocs.org Rev.02/16/00 11