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' UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of _ TYPE OF ACTION .NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specht reason-for local use only) (Specify change-for local use only) ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN 1 P LOCATION WITHIN SITE(OphonaO 431 f2 12-4 10,[4a4nnh2Q I.TANK DESCRIPTION 1��1��rr•••��,,,.. TANK 10 N TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes !No 3 If*Yes*,complete one page for each compo ent. DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 1 00 ADDITIONAL DESCRIPTION(Forlocal use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 011. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑ 2. LEADED El 5. JET FUEL (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED �,3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS N(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 95 LIN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1_ SINGLE WALL X3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER [195. UNKNOWN (Check one item only) /,i}_TZ.�LjUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑gg OTHER TANK MATERIAL-primary tank �K 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ & FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS )!�9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LININGDATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 [3 4. PHENOLIC LINING 1%6, UNLINED El 99. OTHER ❑ 2. ALKYD LININGFor local use only) (Check one item only) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ),3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION i ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all that apply) K 1 SPILL CONTAINMENT 2000 ❑ 1.ALARM X 3. FILL TUBE SHUT OFF VALVE:2.Mo 2. DROP TUBE 12600 f' ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE 0QV IV.TANK LEAK DETECTION IF SINGLE WALL TANK Check alf that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑f 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 012. CONTINUOUS INTERSTITIAL MONITORING ' ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(VR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIALS gallons ❑Yes ❑No 00l.��37 TA' p y'SS3� CUPAFORM Formerly SVVRCB Form B c4/99 � &/3/io