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i 0 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page / of 2 - TYPE TYPE OF ACTION L NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5, CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSU kE 00. (Camkcmhemcmly) P 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED 011 SITE (SperJfy nacom) (Specify recon) 19 S. TANK REMOVED BUSINESS NAME S --•as FACILITY NAME or DBA - Doing Business As 3. FACILITY ID: 1. fG ✓c, 44 FIA /P/?e LOCATION WITHIN SITE (option.0 421. -'/ T. tA* DESCRIPTION AScated.. of lap with -the location ofthe UST $gAjn,inGlydin .Wudio Bqd tiin,dmarks shall:,ye�gubmitted,to,tile.ioppl, gene Y) TANK ID N 43L TANK TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes o 434. U'.//< If-y"cowid.onepage 6r eaN wmpa ..L DATE INSTALLED 435. TANK CAPACITY M GALLONS 436. NUMBER OF COM�{P7ARTM ,NTS (YEAR/MO) v , I X 5�0 V� 417 ADDITIONAL DESCRIPTION (For local me only) 6-A TANK USE 439, PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL 440. ❑ [a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ef choked, complete Petmlaum Tyn) ❑ Ib. PREMIUM UNLEADED C3 3. DIESEL 06. AVIATION GALS' IV �./ 2. NON -FUEL PETROLEUM to. MIDGRADEUNLEADED 04. GASOHOL 99.OTHER: /7 / elL Die- C]yI�/l ❑ 3. CHFMICALPRODUCT COMMONNAME (6om Huardom Matedal9lnvenbry page) /°5' CASN(from Ha dow Matwiab Inventory papa) 4+2. ❑ 4. HAZARDOUS WASTE (Include Uwd NO ❑ 95. UNKNOWN ,c I Iwv,ATI�'Ttt�v�+�4,°r TYPE OF TANK SINGLE WALL UU 3. SINGLE WALL WITH EXTERIOR D 5. SINGLE WALL WITH INTERNAL BLADDER SY 445. (Check one item ordy) MEMBRANE LINER 095. UNKNOWN G�<VC�f 7 ❑ 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-0;m,.mk 1. BARE STEEL 3. FIBERGLASS /PLASTIC 5. CONCRETE ❑95. KNOWN 444. (Check on. hemwly) C1 2. STAINLESS STEEL ❑ 4. STEEL CLAD WffIBERGLASS ❑ . FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTIC FRP W/100% METHANOL TANK MATERLLL-9ecomlary talc I. BARE STEEL 7. FIBE GLASS/PLASTIC6. FRP COMPT BLE W/100%METHAN0L 95. -UNKNOWN 445. (Check mu iremonly) ❑ 2. STAINLESS STEEL O 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NONLORRODABLE JACKET ❑ 99.OTHE REINFORCED PLASTIC (FRF) ❑10, COATED STEEL S. CONCRETE TANK INTERIOR LINING 1. RUBBER LM D 3. EPDXY LINING S. GLASS LININGA5Z.UNKNOWN 446. DATE INSTALLED 4n. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING . UNLINED ❑ 99. OTHER Check one imm ad OTHERCORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC J445. UNKNOWN 449. DATE INSTALLED 449. PROTECTION PROTECTION - ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER IfA liceble 2. SACRIFICIAL ANODE SPILL D VERFILL YEAR INSTALLED/se, TYPE 455. OVERFILL PROTECTION EQUIPMENT: YEARINS AAL D 452. (Check all duupply) ❑ I. SPILL CONTAINMEN ❑ 2. DROP TUBE ` ❑I. ALARM _ 03. FILL TUBE SHUT OFF V (_12. BALL FLOAT VE_ 3. STRIKER PLATE _ ❑ 4. EXEMPT IV. TANK LEAK T ZW"ON+ (A descripli.on-oEthp monitoring progrant Sha0esub6b 0;(o,.tbalapal agangy.) IF SINGLE WALL TANK 4s3. IF DOUBLE WALL TANK OR TANK WITH BLADDER +54. (Check all that apply) (Check mss item only) ❑ 1. VISUAL (EXPOSED PORTION ONLY)1�5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ S. TANK TESTING (SIR)+ BIENNIAL TANK TESTING ❑99. OTHER TAV ,CY OSCAR 'TwOL25!'"ON;I 4'LnR4A,,'NEN� ;01140 ilT1EIN� T CE ESTIMATED DATE LAST USED(YR/MO/DAY) 45. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT Ma IAL? gallons ❑ Yes ❑ No UPCF hwfwre-b (1/99) -1/4 http://www.unidocs.org Re�. 02/16/00