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UNIFIED PROGRAM CONSOLIDATED FORM Itank) TANKSUNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages p Page of TYPE OF ACTION ❑ 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 (Specify reason) (Specify-0 ❑ 8.TANK REMOVED BUSINESSNAME(Same,asFACILITY NAME orDBA-Doing Business AS) 3. FACILITYID: 1 LOCATION WITHIN SITE(optional) rZ 6>^ 3 n n� � 431 L TANK DESCRIPTION L G f (A scaled.plot plan with the location of they UST system including buildings and landmarks shall be submit ed.to the local agen .) TANK ID# 432 T K MANUFA R 433• COMPARTMENTALIZED TANK 21fes ❑ No 434. If TA b 2 3 j$b Z If"Yes"complete one page for each compartment DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS 437. (YEAR/MO) _ ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANr,USE 439• PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED �❑2LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) Ell� Ib. PREMIUM UNLEADED j<DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑(c. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (fmmHszardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195. UNKNOWN ®'L. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE [195.UNKNOWN 444. (Check one dem only) ❑2. STAINLESS STEEL JWO. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICFRP) W/100%METHANOL TANK MATERIAL-secondary tank El 1. BARE STEEL El 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL�j 1. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED 3.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑I.MANUFACTURED CATHODIC3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARSTALLED 450. TYPE 451. OVERFILL PROTECTIO EQ NT: YEAR INSTALLED (Check all that apply) SPILL CONTAINMENT LGA Ell.ALARM 2_-1!!1. L TUBE SHUT OFF VALVE fibi ,. 2.DROP TUBE [a2.BALL FLOAT�❑4.EXEMPT N-?STRIKER PLATE u 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 454. (Check all that apply) (Check one item only) ❑I.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1. UAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.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. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidoes.org Rev.02/16/00