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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page of_ 51 TYPE OF ACTION 06 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spenifyroason) (Specify-) ❑ 8.TANK REMOVED BUSINESS NAME(SamcasFACILITY NAME orDBA-Doing Business As) 3. I FACILITY ID: 1 Cta; i/1 I® + LOCATION WITHIN SITE(optimal) 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 Ll Yes No 434. (VIern WeA it/1,. If"Yes,^complete one page for each comlmitn nt. DATE INSTAL D 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. 91000 t ADDITIONAL DESCRIPTION(Forbcal use only) 43A U.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (ifchecked,cornpletc Petroleum Type) &M PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON Nt1N1E(from Hazardous materials inventory page) 441' CAS#(from Hazardous Materials inventory page) 4-42. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [IS. 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 . BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check 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. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑I.RUBBER LINED ❑3.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 only) OTHER CORROSION L 1.MANUFACTURED CATHODIC 913.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 449. DATE INSTAILED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER PrQp4 (IfA licable) 2.SACRIFICIAL ANODEQ QQ3 SPILL AND OVERFILL YEAR INS ALLED 450. TYPE 451. OV FILL PROTECTION EQUIPMENT: YEAR INSTALLE 452. (Check all that apply) RrI.SPILL CONTAINMENT 01 ALARM FILL TUBE SHUT OFF VALVE M�1.DROP TUBE t `• g�(( ❑2.BALL FLOAT ❑4.EXEMPT STRIKER PLATE !• !e t�t1/1 IV.TANK LEAK DETEC ON (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) [12.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 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 QUANTITY OF SUBSTANCE REMAININGTANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00