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�\�l n"o\ 71z,le-) UNIFIED PROGRAM CONSOLIDAT ORM& TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tang) Page�of TYPE OF ACTIONEW PERMIT El4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANKCLOSURE 430. (Checkone ltemmdy) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Sp<cify«son) (Specify'....) .TANK REMOVED DUSINESS NAMF r4•-•,.pAalmf4M�4Eer DBA-Doi. Business As) J. FACILITY iD: FL6tlu3* 1' 6-1-2-57 4 v/1 Cf LOCATION WITHIN SITEiomi...1 - f �r 431. I:TANK DESCRIPTION A scaled plot plan Withthe location of the UST system Including.buiWings and landmarks-sha141ie,gubmltted+,to.tl?e loom agency:) T'qN _ <3i TANK MANUFAC 133 COMPARTMENTALIZED TANK Yes o a4. DIt"Yes,'complete one page for each wmpatmenL DATE INSTALLED 436. TANK CAPACITY IN GALLONS 416, NUMBER OF COMPARTMENTS 431. (YE 0 ADDITIONAL DESCRIPTION(For local we only) 438. II'.TANK CONTENTS TANKUSE 419, PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑le. REGULAR UNLEADED ❑2. LEADED El 5. JET FUEL (tfchehad,wmplme PamleamType) [I lb. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ lo. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: _ ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om Hazardous Materials Inventory page) 441. CASH(6om Harudom Mnaials lnyenbry page) 443. 0 4. HAZARDOUSWASTE (Includes Ua.d Oil)0Cpo (1 Q' 95.UNKNOWN,OO DiL III: ANIG CONSTI2i�CTIO TYPE OFTANK SMGLB WALL ❑3. SINGLE WALL WITH EXTERIOR O 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Chock one item only) MEMBRANE LINER 095. UNKNOWN 2._DOUBLE WALL Q 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tat . ARE STEEL El 3. FIBERGLASS/PLASTIC 05. CONCRETE 095.UNKNOWN 444. (Chwk one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99,OTHER: REINFORCED PLASTICFRP W/100%METHANOL TANK MATERIAL-secondary tam 1. BARE STEEL 3. FIBERGLASS/PLASTIC 8, FRP COMPfIBLE W/100%METHANOL 0 95.UNKNOWN 445. (Check ora itamonly) /� ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER / REINFORCED PLASTIC(FRP) ❑10. COATED STEEL S. CONCRETE TANK INTERIOR LINING 4.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING UNKNOWN 446. DATE INSTALLED 44'7. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one item onl OTHER CORROSION ❑I.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC UNKNOWN 449. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If Applicable 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 45o. TYPE 451, OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Cl.ck all t ply) ❑1.SPILL CONTAINMENT ❑ 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE _ ❑2.DROP TUBE ❑2.BALL FLOAT_ 0 4.EXEMPT 3.STRIKER PLATE IV.TANK LEAK DETECTION' (A description okthe fnomtonng program shall be submRted to Net alagency), IF SINGLE WALL TANK 461. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Cheek all at aPPIY) (Check one item only) SUAL(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 099. OTHER V.TANIt CLOSURE INFO' 4h,1 ON/ PERW,-'N&T-'OL-0�.'p, JO,�,t ESTIMATED DATE T USE YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING /56' TANK FILLED WITH INERT MATERIAL? 4A / X54 gallons ❑Yes pJo UPCF hwf yre-b(1/99).114 blip:/hYiyw.unidocs.org Rev.02/16/00