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i • C0 �" '✓ UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per tank) 19 11 Page_of TYPE OF ACTION MI.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 reason) ❑ 8.TANK REMOVED BUSINESS NAME(Sam asFACILITY NAME orDBA-Doing Business As) 3. FACILITY ID: w 1C> l mat> i.1 I.IT Ccru c vA`3 1� LOCATION WITHIN SITE(optional) L^n ^L 3 431. I.TANK DESCRIPTION S (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID#T/QS/S 7.?_3432- JJK MANUFACPJRER 433. COMPARTMENTALIZED TANK [:]Yes Imo 434. T4a. L ')tAt-F' If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436- NUMBER OF COMPARTMENTS 437. (YEAR/MO� dgq >� ADDITIONAL DES RIPTION(For local use only) 438. IL TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. 93-1. MOTOR VEHICLE FUEL 21a, REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous 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 ❑95. UNKNOWN -2'DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL KD. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICFRP) 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 ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING 3-15.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 21.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER (If A licable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAALLED a5o. TYPE a51. O�V�FRFILL PRO,TECTIO EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) [�1.SPILL CONTAINMENT Z�'ry ETI.ALARM 2i't' ❑3.FILL TUBE SHUT OFF VALVE 2'2..DROP TUBE A [BALL FLOAT c'r"'❑4.EXEMPT [ 3.STRIKER PLATE _� 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) ❑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 INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG El 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 REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00