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Jai 13 03 12: 06p C i e Brown (2V 461 - t 6, 0 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 (T-Ian per t-k) <br /> Page-Lof <br /> O ❑ I.NEW PERMIT ❑ 4.AMENDED PERWT ❑S.CEIANGE OF INFORMATION 0 6.PERMANENTLY Y CLOSED NK UR SITE 430. <br /> TYPE F ACTION T. <br /> (Chock one item only) ❑ 3.RENEWAL PERMIT <br /> (spay maw*) (Speafy remoa) ❑ 8.TANK REMOVED <br /> 1. <br /> BUSINESS NAME(Same u FACILITY NAMF•;a DIIA-Doing IIus;acm As) 3. FACILITY ID: T=L 1 <br /> 431. <br /> LOCATION WITHIN SITE tOpaioosl) <br /> ' H7 L R� <br /> L TANK D SCRUPTION <br /> (A staled plot plan with the location of the UST system includin buildings and landnsak s shall be submitted to the local agency.) <br /> ANK ID P?' Oo13. Y0/ <br /> 432. TANK MANUFACTURFsR °� COMPARTMbNTAL17,ED TANK ❑Yes No 434. <br /> t C U`Ycs.'t:ompMc one gage foreadr compmtmmr. <br /> n "+1 C1 i NUMBER OF COMPARTMENTS <br /> DATE INSTALLER <br /> 435. TANK CAPACITY IN GALLONS 436. 437. <br /> (YEAR/MO) <br /> Li , 1 J U, 439. <br /> ADDITIONAL DESCRIPTION(For tool use owy) <br /> IL TANK CONTENTS <br /> 440. <br /> TANK USE 439 PF,TROLEUMTYPE <br /> IN 1. MOTOR VEHICLE FUEL ®Ian-REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL. <br /> (Ifdwked,wmptetePetrOkurn TYPO ❑Ib. PR0AEUM UNLEADED ❑3. DIESEL Q 6. AVIATION GAS <br /> ❑ 2 NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED El 4. GASOHOL ❑99.OTHER' 442. <br /> 44t. CAS#(from H-dous I.tatcriats Fn--y paw) <br /> ❑ 3. CHEMICAL.PRODUCT COMMON NAME(from Ilamdous mataiats lnrcmmy page) <br /> ❑ 4.HAZARDOUS WASTE, <br /> (lackrdcs Used 0;I) C �. <br /> r n. <br /> C-. <br /> ❑ 95.IINirNowx <br /> uL TANK CONSTRUCTION <br /> TYPE Or TANK ❑1. SINGLE WALL 3. SINGLE WALL WL7'IIEXTERIOR ❑5.SINGLE WALL WC{IT INTERNAL BLADDER SYSTP.M 443. <br /> ((bade one item only) MEMBRANE LINER ❑95. UNKNOWN <br /> H2.DOUBLE WALL ❑4. SIN=-W ALL IN A VAULT ❑99. OTIIER 444. <br /> TANK MATERIAL-priamy tank I.SARK STEEL 3.FIBERGLASS/PLASTIC 5. CONCREI E 95.UNKNOWN <br /> (Check one item Doty) ❑2.STAINLESS STEEL M 4. STEEL CLAD W/FIRERGLASS ❑S.I COMPATIBLE <br /> O M ATIBL OL 0 99.OTHER: <br /> REINFORCED PLASTIC(IRP 445 <br /> TANK MATERIAL-secondary tank 1. BARE STEEL ❑3. ITIBERGLASS t PLASTIC 8.FRP COMPTII3LE W/IDD%METHANOL ❑95.UNf.T10WN <br /> EL CLAD <br /> (t hed one item Doty) ❑2. STAINLESS STEEL$I 4.ST REINFORCED PLASTCCWMMGLASS 0 9.FRP(7(FRP) 13 ID. COATED STEEL ABLE 7AC1.7 1 ❑99-OTHER <br /> ❑5. CONCRETE 446, DATE INSTALLED 447. <br /> TANK IN'IF.R10R LINING -IRU:BERLTNED 3.EPDXY LINIT7(s 5.GLASS LINING 95.OT14ER <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHI7t <br /> Cheat one item on 448. DATE INSTALLED 449. <br /> OTHER CORROSTON ❑1.MANUFACII: -D CATHODIC 3.FIBERGLASS REINFORCED PLASCIC ❑❑ UNKNOWN <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT 99. <br /> THM <br /> A icablc ❑2.SACRIFICIAL ANODE 45t. P <br /> PROTECTIONI tZi1iPMENT' YEAR INSTALLED 4S2' <br /> SPILL AND OVERFILL YEARINSTALLED 450. TYPE ALARM ®3.FILL TUBE SHITE OFF VALVE C_I.[)5 <br /> (Check all that apply) ®1.SPILL CONTATNMENTO ik'7 BALL FLOAT <br /> ❑4.EXEMPT <br /> ®2.DROP'TUBE CI�C�p.i 5.L1i <br /> R1 3.STRIKER PLATE✓L ' <br /> IV.TANK LEAK DETEC11ON <br /> (A description of the monitoring program shall be submitted to the local agent _) 454 <br /> 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLE WALL TANK (fid one item Only) <br /> (Coed all that apply) <br /> ❑1_VISUAL(E,1(POSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) Q 6.VADOSE ZONE N 2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG ❑7-GROUNDWATER ❑3.MANUAL MONITORING <br /> E)4.STATISTICAL INVENTORY RECONCU.IATION ❑8.TANK TESTING <br /> (SIR)+WENNIAL TANK TFS'L'ING ❑99. OTHER <br /> V. TANK CLOSURE INFORMATION 1 PERMANENT CLOSURE IN PLACE <br /> 455. ESTIMATED QUANTITY OF SITBS?ANCE REMAINING ate' TANK FILED WTIH INERT MATERIALT <br /> 457. <br /> ESTIMATED DATE LAST USED(YIIlMO/DAY) ❑yes ❑ No <br /> sallans <br />