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® Q�011 - UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT 0 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item Only) 0 3.RENEWAL PERMIT A P"At 5 ❑ 7.PERMANENTLY CLOSED ON SITE (Sp-fy,rawn) (Specify M-) ❑ S-TANK REMOVED JB ESS NAME(Same u FACUXrY NAME or DBA-Doing 8osiness As) 3- FACILITY ID: r1�10N WITHIN SITE(Optioml) 431 0 - c r C.,c. Ci S 6 L TANK D SCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID#9 7' f c, 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes L1 No 434. C f\ If-ym"complete one page for each compartment DATE INSTALLED 435- TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS h 437. (YEARIMO) \'`l�\(101�� ,O o O o 0/v ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE . 439. PETROLEUM TYPE 440. OKI.MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5- JET FUEL (If dtecte4 complete Pwokum Type) ❑lb. PREMIUM UNLEADED �3.DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic.MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑ 3- CHEMICAL PRODUCT COMMON NAME(from Ilaakdms Materials Inventory pegc) 441. CAS#(from Eb dotu Mataiah Imventory page) 442. ❑ 4. HAZARDOUS WASTE (Incudes Used Oil) ❑ 95.UNKNOWN A IM TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WTTHEXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkone item only) MEMBRANE LINER. ❑95. UNKNOWN �i 2.DOUBLE WALL ❑4- SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary rant U 1.BARE STEEL U 3. FIBERGLASS/PLASTIC U 5- CONCRETE 1395.UNKNOWN 444- (Chcct one item only) ❑2. STAINLESS STEEL MC4. STEEL CLAD W/FIBERGLASS ❑S.FRP COMPATIBLE ❑99.OTHER- REINFORCED THERREINFORCED PLASTIC W/100%METHAN01, TANK MATERIAL-secondary tank El I. BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑8.FRP COMPTIBLE W/100%METHANOL ❑95-UNKNOWN 445. (Check one item oWy) ❑2. STAINLESS STEEL 104. STEEL CLAD W/FIBERGLASS ❑9-FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10- COATED STEEL ❑5_CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING D 5.GLASS LINING Ej 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 0 6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION 01 -MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 449. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) .SPILL CONTAINMENT 1~y 'K ❑1.ALARM 113.FILL TUBE SHUT OFF VALVE a� 1 t2.DROP TUBE 1=y R ❑2.BALL FLOAT_ ❑4.EXEMPT STRIKER PLATE S Tia a: IV.TANK LEAK DETECTION (A description ofthe 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) ❑2-AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTTITAL MONITORING [13-CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING [14- 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- TANK FELLED WTIH INERT MATERIAL? 457 dons 0 Yes 0 No