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•4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> it TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 <br /> (Two Pages per tank) <br /> TYPE OF ACTION I.NEW PERMIT, Page`of Z <br /> i ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION 0 6.TEMPORARY TANK CLOSURE 430. <br /> (Check one ham only) ] 3.RENEWAL PERMIT <br /> ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify reason) (Specify rcamn) ❑ 8.T/ �FCEMOVED� - <br /> BUSS+INESS NAME(Same u FAC111TY NA&M or DDA-Doing Business As 3. FACILITY ID; f� <br /> J �+ t C S✓� /(-, Gam.' ! 7: I. <br /> LOCATION WITHIN SITE(optional) <br /> "< f 431. <br /> ,. � .TANTO 1?1;S'CRIP`I'I9N <br /> (A seated;,lot :late wtth:the location.vf the U,S; syslein inclydln ¢titldings <br /> TANK ID# 43and l.?ndmarks shall 4e subrrsitted to t(e lwal;agent-,) <br /> 2 TANK 1v1AN tUFACTURER 43)• COMPARTT+MENTALIZED TANK Yeso <br /> J�r� 434. <br /> v / tf"Yes,"wmplale one page for each wmpw,m , <br /> DATE INSTALLED 415. TANK CAPACITY IN GALLONS 416, <br /> (YEAPJMO) ,) ?/' � NUMBER OF COMPARTMENTS <br /> /v /` � , 437 y <br /> ADDITIONAL DESCRIPTION(For local use only) t_,__ � F <br /> /111sGr <br /> TA. CONT,E <br /> TANK USE 47 q• PETROLEUM.TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL 0 la, REGULAR UNLEADED , ❑2. LEADED 640' <br /> (Ifchecked,wmplele Petroleum Type) ❑S. ]FI'FUEL . <br /> ❑lb. PREMIUM UNLEADED ❑3. DIESEL' ❑6, AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic, MIDGRADEUNLEADED ❑4. GASOHOL <br /> ❑99.OTHER: F Y <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (fromHuardousMaleriafslnyw1orypage 441. <br /> [] 4. HAZARDOUS WASTE ) CAS#(from Huudous Matuiala lnventorypage} 442. <br /> (tncludes Uacd oil) � �/�✓L/¢�L I� (;/ - - <br /> ❑ 95.UNKNOWN <br /> MEMBRANE LINER0 <br /> TYPE OF TANK SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR <br /> 7 6N T� <br /> (Check one item only) 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441. <br /> 2. DOUBLE WALL ❑95. UNKNOWN <br /> ❑4. SINGLE WALL[N A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary lank 1. BARE STEEL ❑3. FIBER LASS/PLASTIC <br /> E <br /> (Check NKNOWN 44q. NESSS <br /> STEEL ❑q, STEEL CLAD W/FIBERGLASS [] , FRP COMPATIBLE 4 <br /> i'' REINFORCED PLASTIC FRP a ❑ 9.OTHER: <br /> W/100/o METHANOL <br /> TANK MATERIAL-secondary tank l- BARE STEEL 3. FIBERGLASS IPLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. <br /> (Check one item only) 2, STAINLESS STEEL❑4, STEEL CLAD WIFIBERGLASS <br /> ❑9. FRP NON-CORRODABLE JACKET ❑49.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL, <br /> TANK INTERIOR LINING I:RUBBER LINED. ❑3.EPDXY LINING 5.GLAS LINING UNKNOWN 446. DATE [STALLED 447. <br /> OR COATING ❑2.ALKYD LINING ❑4,PHENOLI �4,UNLINED <br /> Cheek one item onl C LINING i ❑99,OTHER <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 4!!9-95,UNKNOWN 443. DATE INSTALLED 449. <br /> PROTECTION PROTECTION h C14:IMPRESSED CURRENT <br /> [fA licable 2.SACRIFICIALANODE ©99.OTHER <br /> SPILL AND pVERF1LL YEAR INSTALLED/450- TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. <br /> (Check all that apply) ❑1.SPILL CONTAINMENT l+�{�/p <br /> ❑2.DROP TUBE �. ❑I.ALARM ❑3.FILL TUBE SHUT OFF VALVE <br /> 3.STRIKER PLATE C12.BALL FLOAT ❑4,EXEMPT <br /> .(A.:dc the m_onitormg::rograrnshal}be su6ril(tetl Yo ttieaocSl agency:), <br /> [IFSINGLE WALL TANKeck als that apply) IFDOUBLE WALL TANK OR TANK WITH BLADDER4541. VISUAL(EXPOSED PORTION ONLY) �4.MANUALTANK GAUGING MTG (Check one item only) <br /> v ( ) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 2.AUTOMATIC TANK GAUGING{ATG) ❑6,VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> 3, CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> 4,STATISTICAL INVENTORY RECONCILIATION ' ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> TANK GLOSI3RE'Ii�ITOAYIOI�I/ ERANEN CLOSURE II� 1IC <br /> ESTIMATED DATE LAST USED{YR/MO/DAY)i 451. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457- <br /> gallons <br /> gallons ❑Yes ❑ No <br /> UPCF hwfivrc-h(1199)-114 hitP:1/www.uniducs.org Rev.02/16100 <br /> r � <br />