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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 1 (Two pages per tank) t Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5L 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT A) ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED I. BUSINESS NAME(SameasFACILrrYNAMEarDBA-Doing Business As) 3. FACILITY ID: EEE= ® 431. LOCATION WITHIN SITE(optional) I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local age mcy.) TANK ID# 432. TANK MANUFACTURER 433• COMPARTMENTALIZED TANK 1 Yes No 434. If"Yes,:,complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS a36. NUMBER OF COMPARTMENTS 437. (YEAR/MO) ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440' 1. MOTOR VEHICLE FUEL la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ®lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory rgige) 442' ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑L SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLA;i)DER 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 : BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNG WN 444. (Check one item only) 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER,; REINFORCED PLASTICFRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL . FIBERGLASS/PLASTIC 8. FRP COMPTIBL.E W/100%METHANOL �., 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-COR.RODABLE JACKET 1„j 99,OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING S.GLASS LINING 95.UNKNOWN 446, DATE INSTALLED 447. OR COATING [12.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 licabl ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INST LED 450. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED i 452 2 (Check all that apply) 1.SPILL CONTAINMENT [11.ALARM 193.FILL TUBE SHUT OFF VALVE!»� .DROP TUBE ❑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) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONIT[)RING ❑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. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456.T7TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yt i ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidoes.org; Rev.02/16/00