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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page of 77 TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one ham only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-forlocal uaconly) (Specify name-for locsllme only) ❑ 8 TANKREMOVED 430 BUSIN SS NAME(Same FACILITY NAME oa�r DORR-D�oy'p�gEusinrc7es Aa) FACILITYID: Rl Yuk_V1 1 10cV ' t� l l 3 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[D$ 032 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes NJ No 434 00I`IY IP'Yes",complete ane page for each cone marenl. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 Qk L40 21, C00 ADDITIONAL DESCRIPTION(Far local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED 5. JET FUEL Oftearkedcomplem Penolcum Type) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Haroad as Mannish Inventorypage) 041 CAS#(fiom Hazardous Materials Invnnmry page) 442 [14. HAZARDOUS WASTE (Include Used Dip ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK I. SINGLE WALL 3. SINGLE WALL WITH LJ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER El 95, UNKNOWN 02, DOUBLE WALL ❑4. SIGNLE WALL IN VAULT El99. OTHER TANK MATERIAL-primary lank 1. BARE STEEL 3. FIBERGLASS/PLASTIC LJ 5. CONCRETE 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.i FRP COMPTIBLE W/11010%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC I. CONCRETE 95. UNKNOWN 445 (Cbeckone iternmay) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [311. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑(0.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED Lj 3.EPDXY LINING �,U 5.GLASS LININ(( 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING x16 UNLINED ❑99 OTHER (Cls ckonc item only) (Far heel use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC �aDp,9{(3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 4411 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Far local use only) SPILL AND OVERFILL/ YEAR INSTALLED 11ga 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED ( 40 452 (Check all mp that apply) 1 SPILL CONTAINMENT ❑I ALARM ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A description of the northering progumn shall be submined to me local Marcy.) IF SINGLE WALL TANK(Check all ritually) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I 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 [18 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 1 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B