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01 wOTA UNIFIED PROGRAM CONSOLIDATED FORM " g� TANKS 1 UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: 1. LOCATION WITHIN SITE(Optional) 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 agency.) TANK ID# )1 432. T�pN•K/M�iA'NNUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes No 434 ` `© +'r3 33 ! `�[kD ��j If"YM"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS (YEAR/MO) -7- 11111 ' 1 /` 1 -157,666 15'Q66 437 ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE A1. MOTOR VEHICLE FUEL Ia. REGULAR UNLEADED ❑2. LEADED440 (Ifchecked,complete Petroleum Type) ❑5. JET FUEL ❑A. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOWN DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE 1195.UNKNOWN q4q (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN a45. (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [715. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED Lj 3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. (C COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION 0 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION 4.IMPRESSED CURRENT ❑99.OTHER IfA licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR IN ALF 450. TYPE 451. OVERFILL PROTECTION EQ IPMENT: YEAR INSTALLED ase. (Check all that apply) L SPILL CONTAINMENT ❑1.ALARM -3.FILL TUBE SHUT OFF VALVE _.DROP TUBE ❑2.BALL FLOAT //❑❑4.EXEMPT [13.STRIKER PLATE 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 that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑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 ❑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 ash. TANK FILLED WITH INERT MATERIAL? 45-7 gallons ❑Yes El No UPCF hwfWrc-b(1/99)-1/4 http://Www.unidocs.otg Rev.02/16/00