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NIFIED PROGRAM CONSOLIDATED FIRM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1e����o 3 <br /> (Two pages per tank) <br /> Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT /A0 b i F I C ATf a&( ❑ 7.PERMANENTLY CLOSED ON SITE <br /> i <br /> (Specify reason) (Specify reason) ❑ 8.TANK REMOVED <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: 1 <br /> Q v t V_ 5-rop 3 Ck !o✓�q <br /> I I ITI <br /> LOCATION WITHIN SITE(Optional) 431 <br /> I.TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 432• TANK MANUFACTURER 433• COMPARTMENTALIZED TANK El Yes No 434. <br /> �Tlt <br /> 75 <br /> big I L4 I X E(L X E S If"Yes,"complete one page for each compartment. <br /> DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 <br /> (YEAR/MO) , 19 F J Z f 000 <br /> ADDITIONAL DESCRIPTION(For local use only) 438 <br /> II.TANK CONTENTS <br /> TANK USE 439• PETROLEUM TYPE 440. <br /> IQ I. MOTOR VEHICLE FUEL 11 la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (If checked complete Petroleum Type) ❑Ib. PREMIUM UNLEADED <br /> ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441• CAS#(from Hazardous Materials Inventory page) 442. <br /> ❑ 4. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. <br /> (Check one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER <br /> TANK MATERIAL-primary tank ❑1. BARE STEEL 3. TI <br /> FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444. <br /> (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 8. FRP COMPATIBLE ❑99.OTHER: <br /> REINFORCED PLASTIC(FRP) 100%METHANOL <br /> TANK MATERIAL-secondary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC 8. FRW/P COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. <br /> (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET <br /> ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> 5. CONCRETE <br /> TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. <br /> OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING W6.UNLINED ❑99.OTHER <br /> (Check one item on ) <br /> OTHER CORROSION 1.MANUFACTURED CATHODIC C1 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449, <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT <br /> ❑99.OTHER <br /> (If Applicable) 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL,.,r YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQj1IPMENT: YEAR INSTALLED 452. <br /> (Check all that apply) E1 1.SPILL CONTAINMENT ❑1.ALARM ®3.FILL TUBE SHUT OFF VALVE 5Y <br /> ®2.DROP TUBE _�� ❑2.BALL FLOAT ❑4.EXEMPT <br /> 3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted to the local agency.) <br /> IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. <br /> (Check all that apply) (Check one item only) <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL M VAULT ONLY) <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455• ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. <br /> gallons ❑Yes ❑ No <br /> UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00 <br />