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UNIFIED PROGRAM CONSOLIDATED FORM / TANKS V UNDERGROUND STORAGE TANKS - TANK PAGE I 71ZI l07 (Two pages per tank)_"? Pageof-!5� TYPE OF ACTION EW PERMIT El4.AMENDED PERMIT c) 5.CHANGE OF INFORMATION Cl 6.TEMPORARY TANK CLOSURE no. (Chak ane item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ONSITE (Svecify reason) (Spesiry namn) ,TANK REMOVED _-- -USIN SS NAMn'a=+..�..=FACILITY NANIE or DBA-Doing mess ns)_3. FACILITY ID: i.00AT10N WITI(IN SITE_fo_o1ma.IS- _ I."J' f + 1 GL l Q� J'J- 2--_ 411. I.TANK DESCRIPTION' (A scaled: of Ian With the location Of the UST system.inclpoing buildings and,lar.IQmarks-shall be submitted to the,lofplagency.). T A Q�/� °J1 TANK MANUFAC 111. COMPARTMENTALIZED TANK Yes o a4. ATEMSTALLED ass. B"Y=a."wmvlm<on<v.g<m=<am eompanm<nt TANK CAPACITY IN GALLONS 416. NUMBER OF COMPARTMENTS (YEAR/ O an. ADDITIONAL DESCRIPTIO (For loealos<only) 418. II. t ANK�QNx rrN�s TANK USE a9. PETROLEUM TYPE I,� 1, MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED 440. (Ifchack.d.wmploe Navl=om Typ<) LEADED ❑5. JETFUEL ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED 04. GASOHOL 099.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ffom Hazardous Maledalalnvmla rypage 441 CAS#(ffom}iaurdova Mnviab ln5bnlery page) 441. ❑ 4. HAZARDOUS WASTE ('� ( �+Includu VsW OiQ 6�JQ��1/L -(,1V UNKNOWN III 2NSTIiT 'lCl1 TYPEOFTANK . SINGLE WALL Cl 3. SINGLE WALL WITH EXTERIOR (Check one itemody) MEMBRANE LINER ❑5. SING WALL WITH INTERNAL BLADDER SYSTEM 441. 2. OUBLEWALL 4. SINGLE WALL IN A VAULT ❑95. UNKNOWN TANK MATERIAL-primary Ian ARE STEEL ❑99. OTHER ❑3. FIBERGLASS/PLASTIC ❑I. CONCRETE ❑95.UNKNOWN (Cheri on<imm only) ❑2. STAINLESS STEEL ❑4, STEEL CLAD W/FIBERGLASS 44°' ❑8, FRP COMPATIBLE ❑99.OTHER: TANK MATERIAL- REINFORCEDFPLASTIC FRP W/ %METHANOL saondary mnk 1. BARE STEEL 3. FIBERGLASS/PLASTIC 9. FAP COMPTIBLE W1100%METHANOL 95.UNKNOWN 445. (Check one item only) 1� ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS N G ❑9. FRP NONCORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL S. CONCRETE TANK INTERIOR LINING 4.RUBBER 4MED 3.EPDXY LINING 5.GLASS LINING C COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED UNKNOWN 446. DATE INSTALLED 44v. Check one item ord ❑99.OTHER OTHERCORROSION ❑1.MANUFACTURED CATHODIC 113.FIBERGLASS REINFORCED PLASTIC UNKNOWN PROTECTION PROTECTION ❑4.IMPRESSED CURRENT 449. DATE INSTALLED 449. IfA licablc 2.SACRIFICIAL ANODE ❑99.OTHER SPILLANDOVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT:- YEARINSTALLED 452. (Check all t ply) ❑1.SPILL CONTAINMENT ❑I ALARM ❑2.DROP TUBE ❑2BALL FLOAT Cl 3.FILL TUBE SHUT OFF VALVE 3.STRIKER PLATE . ❑4.EXEMPT _- IV.TANK LEAK DETVCTION (A,olimri tion of the monitoring program shall be submitted Co tlicloca)a ency,)., IF SINGLE WALL TANK 451, 1F DOUBLE WALL TANK OR TANK WITH BLADDER (Check all m apply) 454 (ClbSUAL(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 ❑S.TANK TESTING (SIR)t BIENNIAL TANK TESTING 099. OTHER V.TANK.CLOSURE INFORMATION/ 1 ERi1 NENP T bS l tE II TAC&` ESTIMATE.D`DATE /LAST USED YR/MO/DAY))�7455p ESTIMATED QUANTITY OF SUBSTANCE REMAINING °46 TANK FILLED WITH INERT MATERIAL? 451. 6�4✓ti�'t!C' I or(,i �j D gallons ❑Yes P<a UPCF hwrivre-b(1199).1/4 http://www.unidocs.org Rev.02/16/00