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` 7 "2- 1.y; UNIFIED PROGRAM CONSOLIDATED FORM 6 ` TANKS UNDERGROUND STORAGE TANKS - TANK PAGE (Two pages per tank) Page a of X TYPE OF ACTION EW PERMIT ❑ 4.AMENDED PERMIT Cl 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one it..only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Svoufy reason) (Spacir se on) TANK REMOVED @USPIESS NAM3�rc•....v.kCn33YN or DBA Doing siacss As) 5. FACILITY ID: k ='. ©� i r vc N D 1. -LOCATION-WI IbIN 6ITE_(ooiioeal3- ® 0 411, I,TANI{DESCRIPTION' (A scaled;lot Ian With the location of1he UST systep including buildings and Iogdn.j rkS3hai)b,e;;ubmitted;to,.jhe 109 I agency;) T £� 4432. TANK MANUFAC 4u. COMPARTMENTALIZED TANK Yes o u4. If"Y"'"wmplese one Page foreach wmpanmens DA INSTALLED 455. TANK CAPACITY IN GALLONS 43a, NUMBER OF COMPARTMENTS (YE 0 ar. ADDITIONAL DESCRIPTION(Por load meanly) CA 1 44 r y 435. bX.TANK OQY Ti NQS TANK USE +39. PETROLEUM TYPE . MOTOR VEHICLE FUEL 440, ❑ le. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL nfcheckad,wmpine Pnnleum Type) ❑lb. PREMIUM UNLEADED .All DIESEL Cl 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER; CH ❑ J CHEMICAL PRODUCT UCT COMMON NAME (&omHazudous Maleriabinvmlarypage) 441. CA$#(6emHuudow MasvielslnJenloae 441 ❑ 4. HAZARDOUS WASTE NDB ) (Includes Used Oil) I a95.UNKNOWN III. TANK CONS'TR'UC f0N TYPE OF TANK . SINGLE WALL Q3. SINGLE I4ALL WII'II EXTERIOR S. SINGLE WALL WITH INTERNAL BLADDEk SYSTEM 443, (Check ane item ody) MEMBRANE LINER ❑95. UNKNOWN 2. OUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary can ARE$TEFL ❑3. FIBERGLASS/PLASTIC Q5. CONCRETE ❑95.UNKNOWN (Check one it..only) 444. ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑B. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-tecondary msJs 1. BARE STEEL 3. FIBERGLASS/PLASTICS. FRP COMPf18LE (Check one irom only) W/100%METHANOL 95.UNKNOWN 445. � ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/EIBERGLASS ❑9. FRP NON-CORRODABLE JACKET REINFORCED PLASTIC(FRP) ❑]O. COATEDSTEEL ❑99.OTHER 3. CONCREFE TANK INTERIOR LINING F.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING UNKNOWN OR COATING 0 2.ALKYD LINING ❑4.PHENOLIC LINING a46. DATE INSTALLED 4a7, (Check one item only) ❑6.SINLINED ❑99.OTHER OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC UNKNOWN 446. DATE INSTALLED 149, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER &M Lcable 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTAL LED 450. TYPE 4s1. OVERFILL PROTECTION EQUIPMENT:' YEAR INSTALLED 4s2. (Chock all i ply) ❑1.SPILL CONTAINMENT - ❑2.DROPTUBE ❑I.ALARM - ❑3.FILL TUBE SHUT OFFVALVE 3.STRIKER PLATE Cl 2.BALL FLOAT_ ❑4.EXEMPT IV.TANK LEAK DETECTION (A dcscription orthe momtonng:program shall be,submitted to the local ageheg,), t GLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER all at apply) u4. SUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING MTG (Check one item(SINGLE ( ) ❑I.VISUAL(SINGLE WALL M VAULT ONLY) UTOMATIC TANK GAUGING(ATG) Q 6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING IR)+BIENNIAL TANK TESTING Cl 99. OTHER V.TANK CLOSURE INFORMATION/ I ERMA HENT CL©SL11ZEL SEE ESTIMATED DATE LAS USED YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANKFILLED WITH INERT V MATERIAL? 45t. ✓F..�(.C: C, �S' a gallons ❑Yes �o UPCF hwfwre-b(1/99),1/4 liltp://www.unidocs.org Rev,02/16/00