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UNIFIED PROGRAM CONSOLIDATED FORM TANKS X113' r p3 UNDERGROUND STORAGE TANKS-TANK PAGE 1�) lr 3 (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) JI 3.RENEWAL PERMIT LI dc1 A s b e is 14 r Id A;5 ❑ 7.PERMANENTLY CLOSED ON SITE (sir reazon) (may ❑ 8.TANKREMOVED TT- I. BUSINESS NAME(Same as FACIII7Y NAME m DBA-Doing Business As) 3. FACILITY ID: G G (7 3 �. [3 1 431. L ATIO WI SITE(optiomt) L TANKADFSCRIPTION (A scaled plot plan with the location of the UST system including buildings and Iandn3azks shall be submitted to the local agency.) TANK ID#7 %A D 14o Ill a3z. TANK MANUFACTURER 433 COMPARTMENTALIZED TANK [I Yes ❑ No 434. If"Yts,'complete Dere page for each companmmt DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) G, a N 4381 ADDITIONAL DESCRIPTION(For foal use ooVy) IL TANK CONTENTS 440, TANK USE 439. PETROLEUM TYPE 1.MOTOR VEHICLE FUEL ❑la- REGULAR UNLEADED ❑2- LEADED ❑5" JET FUEL (If d wcted.complete Peuvieum Type) Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2.NON-FUEL PETROLEUM ❑lc.MIDGRADE UNLEADED ❑4. GASOHOL ❑99,OTHER Oat CAS#(from Hamdous Materials inventory page) 442. ❑ 3. CFIENIICAL PRODUCT COMMON NAME (from Harndous Materials Iweoeo�'M8e) ❑ 4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN ILL TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITHEXTERIOR ❑5. SINGLE WAIT.WITH INTERNAL BLADDER SYSTEM 443- (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2-DOUBLE WALL ❑4. SINGLE WAIL IN A VAULT ❑99. OTHER TANK MATERIAL-p-erg amk .I- BARE STEEL 3.FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444. (Check one item only) []"2.STAINLESS STEEL a 4. STEEL CLAD W/FBERGLASS ❑8.FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC W/100'/METHANOL TANK MATERIAL,_secondary wk 7. BARE STEEL .FIBERGLASS/PLASTIC [18. FRP COMPTBLE W/700%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99-OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5.CONCRETE TANK INTERIOR LINING 1,RUBBER LINED ❑3.EPDXY LD41NG Lj 5.GLASS IM41NG 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING 0 6.UNLINED [199.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3-IMP FIBERGLASS CURRENT CID PLASTIC 1:195-UNKNOWN eras. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER likable ❑2.SACRIFICIAL ANODE SPILL AND OVERFI YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) I.SPILL CONTAINMENT chi A t V/Z ❑I.ALARM _�3.FILL TUBE SHUT OFF VALVE yCi`� DROP TUBE A Ey ❑2-BALL FLOAT_❑4.EXEMPT STRIKER PLATE 5 Te e J IV.TANK LEAK DETECTION (A description ofthe monitoring program shall be submitted to the local agency_) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. IF SINGLE WALL TANK (Cheek`ah that apply) (Check one item only) ❑1.VISUAL(EJIN)SED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MIG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 12.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 455. 457. ESTB&ATED DATE LAST USED(YR/MOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456" TANK FILLED WITH INERT MATERIAL-? !�� ❑yes ❑ No