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At <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Two pages pItank)Page_ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> (Check om item omy) ❑ <br /> 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (SPmify ten) (Specify reason) ❑ &TANK REMOVED <br /> B INESS NAME{Some FACRSTY NAME or DBA-Doing Business As) 3. FACII TTY ID: <br /> C.-- 431. <br /> LOCATION WITHIN SITE(optiooaq <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks AR1TbeMENTALIZtted ED TANKI ageYes) No a3a. <br /> TANK ID# / 432- TANK MANUFACTURER <br /> 433. co/1 C /ter A 4r---.s if"Yes."complete am page for each compadmem. <br /> DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. <br /> (YEAR/Mo) <br /> • 438. <br /> ADDITIONAL DESCRIPTION(For kxw use only) <br /> H.TANK CONTENTS <br /> 40. <br /> TANK USE <br /> 439. PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUELXiL REGULAR UNLEADED ❑2. LEADED ❑5.JET FUEL <br /> (tfchecked w�oplde Petroleum Type) b. PREMIUM UNLEADED 3 DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM [3IL MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: 44Z <br /> [33. CHEMICAL PRODUCT COMMON NAME(fvm Hundom Materiels Invemory page) 441. CAS#(from Hazardous Mmeriala Iavemory page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Ioekulas used oil) <br /> ❑ 95.uxxivowN <br /> M.TANK CONSTRUCTION <br /> TYPE OF TANK ❑1. SINGLE WALL U3.5ING�LEXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> 443. <br /> MEMBRANE <br /> LINER ❑ <br /> (Check one item only) 95. UNKNOWN <br /> !,1112.DOUBLE WALL 14. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank 1. BARE STEEL 3.FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 444. <br /> (Chock one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS E38.FRP COMPATIBLE 1399.OTHER <br /> REINFORCED PLASTIC <br /> TANK MATERIAL-secondarytank 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑$. FRP COMPTIBLE WlI00°4,METHANOL 95.1JNIINOWN 5. <br /> 4a <br /> (Check otic item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> 13 5. CONCRETE _ <br /> TA K TING OR LINING 0 L2.ALKYD LINING 0 3.EPDXY❑4.PHENOLICWING NG ❑6.UNLINED G ❑qg_07IrFRQ 1 446. DATE INSTALLED 447. <br /> (Check one item onl <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95:UNKNOWN 4a8. DATE INSTALLE 449. <br /> PROTECTION PROTECTION 4.IMPRESSED CURRENT' ❑ <br /> f A ticable 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL ALLED 450. TYPE asl. OVERFfI L PROUn+MENl: YEAR INSTALLED a52 <br /> (Check all that apply) ❑1.SPILL CONTAINMENT g 1.ALARM T�' 3•FILL TUBE SHUT OFF VALVE_ <br /> [3 2.DROP TUBE E32.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 ager .) <br /> 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER as4. <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) 5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑ y CONTINUOUS INTERSTITIAL MONITORING <br /> (32.AUTOMATIC TANK GAUGING(ATG) [3 6.VADOSE ZONE <br /> ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑&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? <br /> asr. <br /> gallons <br /> UPCF hwfwre-b(1/99)-1/4 http://www.unidecs.org Rev.02/16/00 <br />