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UNIFIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ [.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 FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: Mh\N STREET KC-0 K QPM- Kjs ENYeRPats� t F A- ,` 0 !�- LOCATION WITHIN SITE(optional) 431 Iloo S•►APoA S-Cf.EET MAN-TELA C-R g5331 :.TANK DESCRIPTION (A scaled plot plan the location of the UST,system including butldings'and landmarks shall be s[ilimtttedao the local agency);` TANK ID# 432. TANK M/'��/ANUFACTURER 433. COMPARTMENTALIZED TANK ❑ Yes No 434. XF_ E S If"Yes,"complete one page for each compartment. DATE INSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. tig91 1o� l r�,�oo -- ADDITIONAL DESCRIPTION(For local use only) 438, II TANK CONTENTS TANK USE 439, PETROLEUM TYPE 440. I. MOTOR VEHICLE FUEL ❑ 1a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) X1b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441' CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE 'Includes Used Oil) ❑ 95.UNKNOWN I TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE 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 TANK MATERIAL-primary tank El I. BARE STEEL A3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank ❑ I. BARE STEEL 3. FIBERGLASS/PLASTIC [_18. FRP 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 M S GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING "�(6.UNLINED ❑99.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 ❑99.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EOI JIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT 2-CrDl1 1.ALARM 1004 'n 3.FILL TUBE SHUT OFF VALVE 2.DROP TUBE 2tr0 4 2.BALL FLOATI�"Q4.EXEMPT 3.STRIKER PLATE LV TANK LEAK DETECTION - - (A,`,dest nptlon of the monitoring-program shall be'submitted to the local IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑ I. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE X2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00