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i� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 j <br /> (two pages per ta.k) <br /> Page _ of _ <br /> TYPE OF ACTION ❑I.NEW SITE PERMIT ❑ 4. AMENDED PERMIT CHANG IN RMA I0 ❑ S. TEMPORARY SITE CLOSURE <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SIT <br /> ❑3.RENEWAL PERMIT (Specity,mason-for local use only) (Specify charge-for local use only) '�- ❑ S. TANK REMOVED 470 <br /> PT71 <br /> BUSINESS N (Same as FACILITY NAME or OBA-Ooln9 Business As) FACILITY ID a 11 MkILIL :'::11� y I - <br /> Y -.- L <br /> LOCATION HIN SITE(Opbonaq 4312-1 PJ <br /> Gam/[ <br /> t.TANK DESCRIPTION <br /> n0ESCR1, <br /> TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> If'Yei,complete one page for each compartment. <br /> TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> al use only) <br /> III.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> ❑ 1 MOTOR VEHICLE FUEL ❑1. REGULAR UNLEADED ❑ 2. LEADED <br /> (If marked•complete Peholeum Type) ❑10 PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEAOEO ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCTCOMMON NAME(from Hazardous Materials Inventory <br /> page) CAS a(from Hazardous Materials Inventory page) <br /> ❑ 4 HAZARDOUS WASTE(Includes <br /> Used GO <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ t. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. DOUBLE WALL <br /> ❑ 4. SINGLE WALL IN A VAULT ❑94 OTHER <br /> TANK MATERIAL•primary tank ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> ❑ t. BARE STEEL <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ B FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ 1 BARE STEEL El 3. FIBERGLASS I PLASTIC ❑ S. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Check one ilem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ 5. CONCRETE 7 <br /> DATE INSTALLED <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOWN433 <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED 99. OTHER (For Iota!use onl) <br /> (Check one item only) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (For local use only) <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALLFLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> W.TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): <br /> IF SINGLE WALL TANK Check as that s l: <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ t). VADOSE ZONE [32. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 3. CONTINUOUS ATG <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ a. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/OAY) <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> ����o <br /> Yes (C] <br /> ATERIAL? <br /> gallons No <br /> Formerly SWRCS Form B <br /> CUPAFORM(4199) <br />