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d 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 QU.CIJANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT C .AJ ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACII TI Y NAME or DBA-Doing Business As) 3. FACILITY ID: 1 LOCATION WITHIN SITE(Optional) 431. I.TANK DESCRIPTION (A scaled plot plan 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 ❑Yes UL No 434. If Yes,"wmplete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 4JO• NUMBER OF COMPARTMENTS 437. (YEAR/MO) ADDITIONAL DESCRIPTION(For local use only) 438, II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440, ot 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete PenolemnType) ❑Ib. PREMIUM UNLEADED 0,31. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials hwentory,page) 441• CAS#(liom Hazardous Materials Inventory page) 442• ❑ 4. HAZARDOUS WASTE (Inchnies used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary talc 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE ❑95.UNKNOWN 444. (Check one hem only) ❑2. STAINLESS STEEL W STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. 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 ❑6.UNLINED 999.OTHER (Check one item only) OTHER CORROSION 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC C195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If licabk [12.SACRIFICIAL ANODE SPILL AND OVERFILI, YEAR INS LED 45o. TYPE 451. OVERFILL PROTECTIO EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) 1.SPILL CONTAINMENT 1.ALARM ,«�tf .FILL TUBE SHUT OFF VALVED 2.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) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 15L2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑S.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 4%' TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00