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FIED PROGRAM CONSOLIDATED FORM* I N TANK: PR#: UNDERGROUND STORAGE TANKS -TANK PA ��'� FAC#: �- (two pages per tank) Page 2 of 3 TYPE OF ACTION E] 1 NEW SITE PERMIT E]4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION E] 6 TEMPORARY SITE CLOSURE (Chale onlyiron Dory) E] 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT ® ❑STANK REMOVED 430 BUSINESS NAME(same as FACILITY NAME m DBA-Doing Busua,N) FACILITY ID: PR#: PLAZ,P, L.QU FS�- nev 341-, l LOCATION WITHIN SITE(opumnb 431 PHONE t.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) 412 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 `'�� `l 'i IrNm",m�Inca�spage fm mIU m�atmmn ATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 _5-0c)U ADDITIONAL DESCRIPTION(Fmlm,l me only) 438 H.TANK CONTENTS TANKUSE 439 PETROLEUM TYPE 440 ,<MOTOR VEHICLE FUEL ,,❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL ^ (vmahW m�lem Pmoleum Type) DO Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUELPETROLEUM ❑ Ic MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(than Ha .Maiaial,Immtmypagc) µl CAS#(6om H�s Matenai,i.a gpage) 402 ❑4.HAZARDOUS WASTE O.hAs u,edoi0 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chmkawttm nly) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN g 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL.primary tank ❑ I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (C kowimmonly) ❑2.STAINLESS STEEL VSTEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ,,�❑,/3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE E]95.UNKNOWN 445 (Qkamimncnly) E] 2.STAINLESS STEEL �4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBERLINED ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED H7 OR COATING (Chmkam iumonly) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑ 99.OTHER fFmlaal uacamy) OTHER CORROSION ❑ I MANUFACTURING CATHODIC FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED K9 PROTECTION IF APPIACABLE PROTECTION (Chakomitemonty) ❑❑ 2SACRIFICIAL ANODE 4 IMPRESSED CURRENT [j99 OTHER (Pmloml ue Wy) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local we only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chrct all Juupply) �lay�,1 SPILL CONTAINMENT E] I ALARM ,Ey 3 FILL TUBE SHUT OFF VAL' �} 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT W3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A oma:pl+oaarwemom�mk.gptoe,m,lwlbc,abmincdw wclmal,sazr.) IF SINGLE WALL TANK(Chak,ll Ut apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Cmak am imm only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER )912 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 4n ❑Yes ❑ No UPCF(12/99 revised)