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UNIFIED PROGRAM CONSOLIDATED FORM � TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 glv3 (Two pages per tank) Page_Of_ TYPE OF ACTION lir1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE .430. (Clack on<kem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Speeify moon) (Spcciry m+toN ❑ 8.TANK REMOVED I. BUSINESSNAME(sameas FACILITY NAME.,DBA-Doing Bwinem Aa) 3. FACILITY ID: LOCATION WITHIN SITE Optinnd) 431, QJLtA�- I.TANK DESCRIPTION A scaled plot plan with the location of the UST s [em includin buildings landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER u3. COMPARTMENTALIZED TANKW Yes No 434. If'Yea. conplen... .fin enchcampamment. in DATE INSTALLED 435. TANK CAPACITY IN GALLONS 036. NUMBER OF COMPARTMENTS //,, 4n. (YEAR/MO) 2002- Zvf OOO - 0-'10115 ?- ADDITIONAL DESCRIPTION(Fofloael-n*) 438. SC'/OOc)- Ca.Jt�-vTtcJ II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440. )(1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (Ifehecked.e.Wicte Pamlcum Type) C'llb. PREMIUMUNLEADED DIESEL 06. AVIATION GAS [12. NON-FUEL PETROLEUM ❑It. MIDGRADE UNLEADED t4. GASOHOL 099.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (aam Haeardoue Material,Inventory Pape) NI' CAS#(6om Haraedom Mnt.nala Inventory inae) w2' ❑ 4. HAZARDOUS WASTE (IvalWm Umd Oil ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 04. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-pnenar tack ❑1. BARE STEEL W. FIBERGLASS/PLASTIC E3 5. CONCRETE ❑95.UNKNOWN 444. (Cheek one wantonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/IWI.METHANOL TANK MATERIAL-secondary tank 0 1. BARE STEEL P53. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/IBOY METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRPNON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING Lj 5.GLASS LINING 95.UNKNOWN 446, DATE MSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one item onl ) OTHER CORROSION 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 419. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER IfA licable) [12.SACRIFICIAL ANODE SPILL AND OVERFILLYE�t INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT yL ❑I.ALARM -El 3.FILL TUBE SHUT OFF VALVE _ .DROP TUBE 02Y.A-2.BALL FLOAT Ga,❑4.EXEMPT STRIKER PLATE �_Z- 7� W.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local a cy.) 4u IF SINGLE WALL TANK ]451IF DOUBLE WALL TANK OR TANK WITH BLADDER(Cheek all that apply) (Check oro item only) ❑I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGFNG(M ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE W2.CONTINUOUS INTERSTITIAL MONITORING [13.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.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) 433. ESTIMATED QUANTITY OF SUBSTANCE RENAMING 456- TANK FILLED WITH INERT MATERIAL? 57. gallon ❑Yea ❑ No UPCF hwfwrc-b(1/99)-1/4 http9/www.unidocs.org Rev.02/16/00