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AOL A911k. 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 ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chock one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (spccifyrcason) (spocifyreason) 8.TANK REMOVED BUSINESS N (Sarno as FACILITY NAME or DB Doing Bas noes Aa) 3. FACILITY ID: 1. QG1 tA6 - t'A + q T ® ® ® 1�-141-71aj LOCATION WITHIN SITE(optional) 431. I.TANK DESCRIPTION A scaled plot plan with the location of the UST system incl buddin s and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER® ,(( 433. COMPARTMENTALIZED TANK Yes ❑ No 434. ® ef i'1 �/'(�1 if"Ycs-'complete one page for each congtartmcnt. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. `Y °) l q+ ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS T K USE 439. PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifcheckod,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL El 6. AVIATION GAS ❑ 2.NON-FUEL PETROLEUM Ale.MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441. CAS#(fin.Hazardous Materials Inventory page) 441 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. 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 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Chock one itan only) ❑ STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. 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 [195.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL El4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET 9.OTHERT6+&1 REINFORCED PLASTIC(FRP) ❑10. COATED STEELiA 1,en+ '} ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LININGGLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447 5. . OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING .UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (IfA licable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL Y TALLED 45o. TYP 451, OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT &LALARM ❑3.FILL TUBE SHUT OFF VALVE 2.DROP TUBE 2.BALL FLOAT_ ❑4.EXEMPT 3.STRIKER PLATE IV.TANK LEAK DETECTION A description of the momitoring 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 g2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING [199.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. 1 TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00