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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT Pt5.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 BUSINE$ NAME(SameasFACILITYNAMEorD -Doing Business As) 3. FACILITY ID: 1. q . r - LOCATIOCN- lsI_SITC( al)Qa)lsj �� t 0011 C 431. )01 Ll I.TANK DESCRIPTION (A scaled plot pian 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 El Yes El No 434. SIf"Yes,"conode one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/Mo)Lt 1 //{p "7 O� ADDITIONAL DESCRIPTION(For Waal use only) 438• IL TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. L MOTOR VEHICLE FUEL ❑la.REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If checked,completePetroleum Type) TP lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials hwemory page) 441. CAS#(from Hazardous Materials Inventory page) 442• ❑ 4. HAZARDOUS WASTE (Includes Used Oil) PPa ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. 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 0 99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC [15. CONCRETE 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/1�/o METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC E3 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. 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 C3 3.EPDXY LINING K5.GLASS LINING E3 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION 0 1.MANUFACTURED CATHODIC 10 3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION 4.IMPRESSED CURRENT ❑99.OT14ER If A licable 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OYERFILL PROTECTION]EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENTg� 4? 1.ALARM .FILL TUBE SHUT OFF VALVE_ ❑2.DROP TUBE 9 / 2.BALL FLOAT_ 4.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 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454• (Check all that apply) (Check one item only) [11.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455• FESTIMATED QUANTITY OF SUBSTANCE REMAINING 456• TANK FILLED WITH INERT MATERIAL? 457• gallons ❑Yes ❑ No UPCF hwfwm-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00