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UNIFIED PROGRAM CONSOLIDATED FORM IOv TANKS UNDERGROUND STORAGE TANKS -TANK PAGE I (Two pages per tank) Page_of_ TYPE OF ACTION )K1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chmmk om hcm only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (sN6fy reason) (Specify Mason) ❑ 8.TANK REMOVED BUSINESS NAME(SCheymn ameaa FACILITYNAME or DBA-Doing Business N) 3. 1 FACILITY ID: I. rC' LOCATION WHIN SITE(Optional) 431. faMSh� /�1&C 41� r Dfi vgC., I.TANK DESCRIPTION (A scaled plot plan with the location of the UST s tem including buildings and landmarks shall be submitted to the local agency.) TANK ID# a32. TANK MANUFACTURER a33. COMPARTMENTALIZED TANK El Yes Pj No 434. _ If Ym; complete ono page Wr each companment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 431_ (YEAR/MO) 0002 Z O/ 000 - ck.(I ori S ADDITIONAL DESCRIPTION(Fm local.only) 43s II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 'K 1. MOTOR VEHICLE FUEL la. REGULAR UNLEADED [12. LEADED ❑5. JET FUEL (Ifel c kd,coo, c Pnrolcum Type) ❑lb. PREMIUM UNLEADED [13. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADEUNLEADED 04. GASOHOL 099.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ham H.tom M.umau lnvemory page) MI. CAS#(from H.&.Materials lnvetmrypage) 4,12 ❑ 4. HAZARDOUS WASTE (IrchWn Uud Oi9 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPEOFTANK [11. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443_ (Check oneitem only) MEMBRANE LINER [195. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary rank I. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 4s4. (Check om aom only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FTBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 095.UNIOJOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL Cj 5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED U 3.EPDXY LINING Ll 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED Kl. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one item od OTHER CORROSION Ll I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN as. DATEINSTALLED a9. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER (IfApplicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. O RFILL PROTECTION EQUIPMENT. YEARINSTALLED 4R. (Check all that apply) .SPILL CONTAINMENT .1!§I.I.ALARM _ [13.FILL TUBE SHUT OFF VALVE 2 DROP TUBE �l" 2.BALL FLOAT(,7,❑4.EXEMPT WSTRIKER PLATE 4 IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454, (Check all thal apply) (Cheek one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) v❑�/1.VISUAL(SINGLE WAIL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE .CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 0S& TANK FILLED WITH INERT MATERIAL? 411. gallons ❑Yes E] No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00