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ILA UNIFIED PROGRAM CONSOLIDATED FORM I TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 �l'u3 (Two pages per tank) Page_of TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one tem only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify recon) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(same as FACILITY NAME or DBA-Doing Busmcu Au 3. 1 FACILITY ID: I F I I 1. LOCATION WITHIN SITE opriona0 431' I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local a cy.) TANK ID# 432. TANK MANUFACTURER 433' COMPARTMENTALIZED TANK Yes No 434. Ir••vea,'coriplmeoec enae wr e.4n eongranmrnr. Z DATE INSTALLED 435. TANK CAPACITY IN GALLONS 6. NUMBER OF COMPARTMENTS 437, (YEA /MO) z0oZ Z0, 0C O - a.,,oPzS 7- ADDITIONAL ADDITIONAL DESCRIPTION(For local nae only) 438. • - rj - II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440, %1. MOTOR VEHICLE FUEL ❑M/la. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL a (lfch4el.complete Pcrmleum Type) 1p lb. PREMIUM UNLEADED Q3.DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(ft.Hamloua Manerula Inventory page) Ml. CAS#(eom H...rdaoa Marcribhrvemoryluge) 442, ❑ 4. HAZARDOUS WASTE (IrchWca Used Oi0 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OFTANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary rank ❑l. BARE STEEL FIBERGLASS/PLASTIC ❑5. CONCRETE 95.UNKNOWN 444. (Check one hem only) [12. STAINLESS STEEL [14. STEEL CLAD W/FTBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/IOD%METHANOL TANK MATERIAL-secondary BARE STEEL 3. FIBERGLASS/PLASTIC ❑ talc 1. 8. FRP COMPTIBLE W/I001A METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODA13LE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL 5. CONCRETE TANK INTERIOR LINING L RUBBER LINED .E 3PDXY LINING U 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED 442. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED [199.OTHER Cheek one item onl OTHER CORROSION U 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 441l. DATE INSTALLED a9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER if licable [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENTZ ❑1.ALARM [13.FILL TUBE SHUT OFF VALVE_ W.DROP TUBE `Gf2.BALL FLOAT 04.EXEMPT STRIKER PLATE Oy 7� IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) [11.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE V2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.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(Y IMOMAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITHINERT MATERIAL? 451. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 httpJ/www.unidocs.org Rev.02/16/00