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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TS -TANK PAGE 1 (63) pag per Page Of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. { ��i,l l (Chock one item only) [13.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE `C' (Specifymaaon) (Spocifyrcason) ❑ 8.TANK REMOVED 1. BUSINESS NAME(Same aaFACiI.iTY NAME or DBA-Doing Business As3. FACILITY ID: T 1 (� LOCATION WITHIN SITE(Optiotmi) 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.) I cJu TANK ID# 1 437 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes No 434. 15,516-6 -00 „ /_ 0 O M ern �� (�, if"Yca,-mmpictc one page for®ch coogartment. DATE INSTALLp !D GT r 435. TANK CAPACITY IN GALLONS 43� NUMBER OF COMPARTMENTS 437. (YEAR/MO) YrZ)POSed'•VA -2-003 9,000 438 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440• V1.MOTOR VEHICLE FUEL ❑It, REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchccked,complete Petroleum Type) EKb, PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2.NON-FUEL PETROLEUM ❑Ic.MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT441. CAS#(from Hazardous Materials Inventory page) 442 COMMON NAME(6rom HaTardous Materials inventory page) ❑ 4. HAZARDOUS WASTE (Includes Uacd Ol) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) _/ MEMBRANE LINER [195. UNKNOWN $2 DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank . BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95.UNKNOWN 444• (Chock one item only) ❑2. 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. BERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. I►! (Check one item only) ❑2. STAINLESS STEEL '4. STEEL CLAD WIRBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING N A ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER (Check one item on1 ) OTHER CORROSION L 0 1.MANUFACTURED CATHODIC ff3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448, DATE INSTA ED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER Propo •Mow .00-7 (If A licable 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. O RFILL PROTECTION EQUIPMENT. YEAR INSTALL 452 (Check all that apply) �l.SPILL CONTAINMENT / M"'ZlY>3 - ®t•ASMNLL TUBE SHUT OFF VALVE_ Be.DROP TUBE t a. r�(( ❑2.BALL FLOAT_ ❑4.EXEMPT STRIKER PLATE << 14 tett(t IV.TANK LEAK DETEC ON (A description of the monitoring progam 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(MCG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE Lye.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. ESTIMATED QUANY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? a57. ITT gallons []Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00