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UNIFIED PROGRAM CONSOLIDATED FORM A TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages ank Page _ et�n TYPE Of ACTION NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one dem Doty) ❑3.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE ^I i3C V (Specify reason•for local use only) (Spsuy cheeps•lorbcel use Doty) O"l ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing BUsiness As) FACILITY ID 0 ,4. tZ..- �i Tit• LOCATION WITHIN SITE(Opb'onso L 431 e 1.TANK DESCRIPTION TANK 10 N TANK . AGTUREf� ^^^��rrr COMPARTMENTALIZED TANK ID No LL 11-Yes',complete one page for each com arbnent. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS Z66,2 06 ADDITIONAL DESCRIPTION(Forlocal use ontyl 11.TANK CONTENTS l7`�/� TANK USE 432 PETROLEUM TYPE •T. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ]f2 LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED DIESEL ❑ 6. AVIATIONFUEL 2. NON•FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(from Hazardous Materials Inventory page) CAS 0(from Hazardous Materials Inventorypage) Used Die 95- UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Rem only) ,�2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT 1199, OTHER TANK MATERIAL-primary lank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95. UNKNOWN (Check one dem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ,❑y3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL -sal 4. STEEL CUD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) 1110. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING OR COATING ❑ 1. RUBBER LINED 113. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED 1-12. ALKYD LINING ❑ 4. PHENOLIC LINING 116. UNLINED ❑99. OTHER (Check one item ) (For local use only) PROTECTION IF APPLICABLE OTHER CORROSION CKI. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLEO PROTECTION (Check one item only) EJ4. IMPRESSED CURRENT C199. OTHER ❑ 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) �/�^�_ 1. SPILL CONTAINMENT 1. ALARM K3. FILL TUBE SHUT OFF VALVE 2. DROP TUBE 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV.TANK LEAK DETECTION IF SINGLE WALL TANK(Check an that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item onl): ❑ 1. VISUAL(EXPOSED PORTION ONLY) l ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2: AUTOMATIC TANK GAUGING(ATG) ❑ 0. VAUOSC ZONE C014 I INUUUS IN I ENG LI I IAL MUNI I ORIIJG ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE UST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBST NCE REMAINING 4177Z7� t4 u, _ ~ gallons CUPAFORM(4199) Formerly SVVRC©Form D