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ve UNIFIED PROGRAM CONSOLIDATED FORM Th D620S 3 1 ci 1 TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 ✓ (two pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT CHANGE OF INFORMATION) ❑ 7.TEMPORARY SITE CLOSED CLOSURE SITE (Check one item only) p�p O ❑3.RENEWAL PERMIT (Specify reason•lorlocal uss Dory) (S 9e•for 106 use only) ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY 10# 1 LOCAT, 1 IN SITE(Optic' - *�1 n I.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No Q� � � �� Itm 'Yea',complete one page for each cop rtment. TAN CAPACITY IN GALLONS NUMBER OF COMPARTMENTS DATE INSTALLED(YEAR/MO) � ©^ A,.ITIO L DESCRIPTION(Forloul u s only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL MOTOR VEHICLE FUEL L ❑ 6.AVIATION FUEL �,.njiod, complete Petroleum Type) PREMIUM UNLEADED I �- ❑ 3. DIESEL . NON-FUEL PETROLEUM iT_ ❑ d. GASOHOL ❑99. OTHER ❑tc. MIDGRADE UNLEADED. CHEMICAL PRODUCT COMMON NAME(hom Hazardous Matenals Inventory page) CAS#(from Hazardous Matenals Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used OrQ 1 095. III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑gg. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS I 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/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE OATEINSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED 99.OTHER (Forlocal use only) (Check one item only) OATS INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION [199. OTHER ❑ 4. IMPRESSED CURRENT (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLEDf7jRFILLPROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) 1 SPILL CONTAINMENT 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE DROP TUBE y` 2. BALL FLOAT ❑ 4. EXEMPT �0'3. STRIKER PLATE N.TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item Dory): IF SINGLE WALL TANK Check all that ap ): ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) . ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUSATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• [-IS. TANK TESTING 1 BIENNIAL TANK TESTING [:199. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No Formerly SWRCS Form B CUPAFORM(4/99)