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Ahk Adak 1w Arl- UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page of 5 TYPE OF ACTION I.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chock one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spocify-) (Spocifyrcason) ❑ S.TANK REMOVED BU$ S N (Same as FACILITY NAME or DBA-D inB Busincac 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 La No 434. moatin W e I n If"Yca,"complctc one page for cath compartttsmt. DATE INSTALLED�r® 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) ADDITIONAL DESC TION(For local ase only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 0 00,1. MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchwkcd,wngplcte Pcoolcum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le.MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441. CAS#(from Hw dou,Material,Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. 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 tank 6M. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Chock ow 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. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL&Pe STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LININ [11.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED [199.OTHER (Check one item only) ge OTHER CORROSION ❑1.MANUFACTURED CATHODIC FW3'FIBERGLASS REINFORCED PLASTIC 0 95 UNKNOWN 448. DATE INSTALLED 449, PROTECTION PROTECTION 4.IMPRESSED CURRENT ❑99 OTHER P rO D® 1 (IfA licable) 2.SACRIFICIAL ANODE M A SPILL AND OVERFILLEAR INST LED 450. TYPE 451. OVERFILL PROTECTION EQUI ENT: YEAR INSTALL 452. (Check all that apply) W.SPILL CONTAINMENT [WALARM LL TUBE SHUT OFF VALVE (1.DROP TUBE •• [12.BALL FLOAT ❑4.EXEMPT STRIKER PLATE [/ h �d 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 (Check all that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ,❑1 11.VISUAL(SINGLE WALL IN VAULT ONLY) V. ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.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 456.1 TANK FILLED WITH INERT MATERIAL? 457. uallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00