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r UNIFIED PROGRAM CONSOLIDATED FORMQ)( P_.)r_ TANKS 0 UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION1.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 mason) ❑ 8.TANK REMOVED BUSINESS NAME(SameasFCU ME NAorDBA-Doing BusineasAs) 3. FACID ID: 111(41_�J_jj 1• LOCATION WITHIN SITE(optional) 431. :�oq w , 'H�}mM EfZ LkNe S-'oclL7o1,► I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# '3 G 432• TANK M•nJUFACTURER C 433• COMPARTMENTALIZED TANK Yes No 434. TA { E 3 O" b -F s r Li-L L•Q 'e• If Yes.,,complete one page for each compartment DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS 437. (YEAR/MO) 11 AM, D 4000 O 2000 ADDITIONAL DESCRIPTION(Forlocal useonly) 438. II.TANK CONTENTS TANK USE 439• PETROLEUM TYPE 440. L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (I checked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED . DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED 't4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Humtlotu Materials Inventory page) 441• CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Inches Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-priminytank X. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE0 95.UNKNOWN 444. (Chock one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICFRP) W/100%METHANOL TANK MATERIAL-secondary tank C]L 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) [110. COATED STEEL 5. CONCRETE TANK INTERIOR LINING ❑L RUBBER LINED 3.EPDXY LINING5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION 1.MANUFACTURED CATHODIC W3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [399.OTHER If licable E32.SACRIFICIAL ANODE SPILL AND OVERFIL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check a0 that apply) I.SPILL CONTAINMENT _20M .ALARM 200© FILL TUBE SHUT OFF VALVE 2c00 2.DROP TUBE 2.BALL FLOAT 4.EXEMPT 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 X CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑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 ESTIMAa DATE LAST USED(YR/MO(DAY) 455. ESTIMATED QuANTITY OF SUBSTANCE REMAINING 456• TANK FILLED WITH INERT MATERIAL? 457. ons ❑Yes ❑ No - I,I v/,I d-U vv j UPCF hwfwrc-b(1/99)-1/4 httpJ/www.unidocs.org Rev.02/16/00