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0 lU UNIFIED PROGRAM CONSOLIDATED FORM Il(�Iv2 ' UNDERGROUND STORAGE TANKS-TANK PAGE 1 TANKS 7-4 5 (fsw Pages per lank) Pape _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT K 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check oris Nem only) ❑J.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify reason•for local use only) (Specify change-for local use only) ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10 dry 1 e 0A, 38(0 LOCATION WITHIN SITE(Oph'on*O 431 ^n� e I.TANK DESCRIPTION TANK ID N TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No ttqD5(5(Ql' M 0 b E Q M WE L b ► <� If'Yei•complete one page for each compartment. DATE INSTALLED(YEARANO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 40Z /01 /Z / Dov i ADDITIONAL DESCRIPTION(Forkrca/use only) II.TANK CONTENTS ��y(( TANK USE 432 PETROLEUM TYPE WI'.1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 0 2. LEADED ❑ 5. JET FUEL (ll marked,complete Petroleum Type) C3 1b. PREMIUM UNLEADED g 3. DIESEL 116. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ElIc, MIDGRADE UNLEADED 4, GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT 'e ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(from Hazardous Materials Insenfory page) CAS N(from Hazardous Materials Insenfory page) Used Oil) 1 0 95- UNKNOWN Ill.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ J. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Nem only) :e�2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 114. SINGLE WALL IN A VAULT C199. OTHER TANK MATERIAL•primary lank Ff I. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL•secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ S. FRP COMPATIBLE W/100%METHANOL C195. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4.STEEL CLAD WIFIBERGLASS 5d 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING OR COATING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED �( ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING pl 6. UNLINED ❑99. OTHER (Check one dem SI l (For local use only) OTHER CORROSION ❑ t MANUFACTURED CATHODIC ❑ 3, FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN a34 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 1199, OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all that apply) 9 1 SPILL CONTAINMENT 407- O Z ❑ 1.ALARM ICY 3, FILL TUBE SHUT OFF VALVE ® 2. DROP TUOE C L ❑ 2. BAIL FLOAT ❑ 4. EXEMPT ® 3. STRIKER PLATE © L "I IV,'TANK LEAK DETECTION IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): Cl1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1, VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2, AUTOMATIC TANK GAUGING(ATG) ❑ 0.'VAUGSL ZONE 9 2. CUN I INUOUS IN I Llts 1111AL MUt4l I OIiiilG ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ J. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING,d ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCU Form D