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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUNDSTORAGE TANKS-T PAGE 1 o D Wit) <br /> u, <br /> Page Z of <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION [] MPORARY TANK TLY CLOSED CLOSURE ITE 430. <br /> 7 E <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 8.TANK REMOVED i <br /> _ (Specifyiemn) ( fY. ) 1. ` <br /> TFT_ <br /> BU$�+^�F��-N (Samcaa//Fy�A�CR.FCYNAMyyE��orDBA_"iwincaaAS) 3. FACILITY ID: <br /> lac .G 11tlnt""111 rt_ q_&a6 IFA 431. IB <br /> LOCATION WITHIN SITE(Optional) B <br /> I TANK DESCRIPTION �1 <br /> A scaled lot Ian with the location of the UST system includin btuldin s and 3andnwks s submittedYa No 434. <br /> TANK ID# I 43z TANK MANUFACTURER <br /> l 5 1 �od�,rn �� �� F::::=f0SCj. <br /> t.DATE INSTALLEDa35. TANK CAPACITY IN GALLONS436OFCOMPARTMENTS 437. <br /> (YEAR/MO) . fi D00 <br /> 438. <br /> ADDITIONAL DESC TION(For local use only) <br /> II.TANK CONTENTS <br /> 440. <br /> TANK USE 439• PETROLEUM TYPE <br /> 911. MOTOR VEHICLE FUEL 4. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (Ifckckcd,congdctepenolcamType) ❑lb. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS <br /> ❑ 2.NON-FUEL PETROLEUM ❑Ic.MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ COMMON NAME( 441. CAS#(from Hazardous Materials Itrvwtory Page) <br /> 442. <br /> 3. CHEMICAL PRODUCT from Hazardous Malcriata iovcntory Page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (IncludesUsed Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑I. SINGLE WALL ❑3. SINGBE�W�iINWERH EXTERIOR ®95 SINGLE L WITH INTERNAL BLADDER SYSTEM 4a3. <br /> (Check one item only) OWN <br /> �/ 99. OTHER <br /> �Z DOUBLE WALL ❑4. SINGLE WALL IN AVAULT - �❑ 444 <br /> TANK MATERIAL -primary tank BARE STEEL ❑3. FIBERGLASS I PLASTIC ❑5. CONCRETE ❑95.UNKNOWN <br /> 8. FRP COMPATIBLE ❑99.OTHER: <br /> (Check one iten only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ W/100%METHANOL <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL [33.�FIBERGLASS/PLASTIC <br /> 8. FRP <br /> QCOMPTTBLE W/100%METHANOL ❑95.UNKNOWN 4as. <br /> (Check one item only) ❑2. STAINLESS STEEL 4• STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LININ0T ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING C]95.UNKNOWN 446. DATE INSTALLED 447. <br /> OR COATING N ❑2•ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER <br /> (Check one item only) f®QO� <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC FIBERGLASS REINFORCED PLASTIC 99.OTNHHEERWN 448. DATE INSTALLED449• <br /> PROTECTION PROTECTION 4.IMPRESSED CURRENT ❑ (r p <br /> (IfA licable) 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL EAR INST LED 450. TYPE 451. OV GK. <br /> OTECTTON EQU.FILL 1TUBE1 HUT0�ALVE 45 <br /> (Check all that apply) �•SPILL CONTAINhIENT 3 (❑�22.BALL FLOAT_[❑44•EXEMPT <br /> GRI.DROP TUBE <br /> .STRIKER PL <br /> IV.TANK LEAK DETE ON <br /> (A description of the monitfvll pmgrain shall be submitted to the local a enc .) <br /> 451iF DOUBLE WALL TANK OR TANK WITH BLADDER 454. <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) <br /> C]1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL TI VAULT IT <br /> 2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE MONITORING <br /> ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑ <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99.OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE asz <br /> a55. a56. TANK FILLED WITH IN MATERIAL• <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTTIY OF SUBSTANCE REMAINING ❑Ya ❑ No <br /> gallons <br /> Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-1/4 http://wwwamidm.org <br /> I <br />