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0 .. a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1F071 <br /> (two pages per tank) <br /> X5. Page _ ofTYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT CHANGE OF INF RMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Check one item only) /� �� ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specht mason-for local use only) (Specily change-lorloca/use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Sam FACILITY NAME or DBA-Doing Business As FACILITY ID 0 1 <br /> LOCATION WITHIN SITE(Opdonaq 431 <br /> I.TANK DESCRIPTION <br /> TANK ID <br /> O TANK U ACTURE COMPARTMENTALIZED TANK ❑ Yes No <br /> if ',complete one page for each compartment. <br /> DATE INSTALL­, O) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use <br /> ( 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (if marked,complete Petroleum Type) ❑1E. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL - <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> 3. CHEMICAL PRODUCT CAS II(from Hazardous Materials Inventory page) <br /> 4. HAZARDOUS WASTE(Includes COMMON NAME(from Ha,aid s Materials IJn(�fj(�tory age) <br /> sed Oin17195 UNK <br /> (' y III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> rrrry...��� EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one item only) �2. DOUBLE WALL ❑ q SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item onty) ❑ 2. STAINLESS STEEL X4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> /Check one item 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 <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER (For local use only) <br /> (Check one item on ) DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local use ly) <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL rF - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check alf that apply) I. SPILL CONTAINMENT ❑ 1.ALARM 3. FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN 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(SIR)♦ ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING 1 ❑99, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No /, l <br /> CUPAFORM(4/99) . VFeaCB Form B <br />