Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORMmorio <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TAN PAGE -71X1107 <br /> (Two pages per tank) <br /> TYPE OF ACTION EW PERMIT <br /> Page of_#_ <br /> ❑ 4.AMENDED PERMIT CI 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY TANK CLOSURE u0. <br /> (Chink ona itemoaly) ❑ 7.RENEWAL PERMIT <br /> ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify res n) (5pecifyrmonJ .TANK REMOVED <br /> BUSINESS NAN°'<•-•.<FACILf1YNAME or DBA-Doing Business As) 7. FACILITY ID: 4i '. <br /> LOCATION WITIHN SITE ioodonli_ :,IV` <br /> 451. <br /> I.TANK DESCRIPTION <br /> (A scaled Aof Ian with the location of the UST systean including buildings aqd J4f1,(�IraOrks shall bera brtuttedto the_hasal agency) <br /> - T j...�� +Sx TANK MANUFAC 451. COMPARTMEhTLAL1ZED TANK Yes o q5+. <br /> 'DATE STALLED 455. If"Y<%'wmphm.on.p.ga for<4m mmpmm<m <br /> TANK CAPACITY IN GALLONS v6. NUMBER OF COMPARTMENTS <br /> (YE O / <br /> 437. <br /> ADDITIONAL DESCRIPTION(For local usa only) <br /> 453. <br /> II.TANK COt�E7`s,�N`�'S <br /> TANKUSE 439. PETROLEUM TYPE <br /> ON. MOTOR VEHICLE FUEL440. <br /> ❑le. REGULAR UNLEADED [LEADED ❑5. JET FUEL <br /> (if<h<cted,wmplaa pamlcum I".) ❑lb. PREMIUM UNLEADED <br /> ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑1s. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om Hrzardeus Mme als lnv to d41 CASN <br /> ❑ 4. HAZARDOUS WASTE Np°[6') (fram Haxudous Materials(nvenwryp.g<) 443. <br /> (lndudes Used oil) r_7V L�7V PY(,v" <br /> Q U.UNKNOWN <br /> IIT T'ANT{CON5TiI74IQI „ <br /> TYPBOFTANK SMGLE WALLe <br /> (Check one item only) ❑3 SINGLE WALL WITH EXTERIOR ❑5. SING WALL WITH INTERNAL BLADDER SYSTEM 445, <br /> MEMBRANE LINER [395. <br /> 95. UNKNOWN <br /> 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANKMATERIAL-primary tan ARE STEEL ❑J. FIBERGLASS/PLASTIC ❑5. CONCRETE <br /> (Check one iI<m only) ❑2. STAINLESS STEEL C14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE CI 95.UNKNOWN q4q, <br /> REINFORCED PLASTIC FAP ❑99.OTHER: <br /> TANK MATERIAL-seconds tank W/100%METHANOL <br /> N I. BARE STEEL 3. FIBERGLASS/PLASTIC S. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. <br /> (Check ona item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑S. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINQNG 5.GLASS LINING UNKNOWN 446. DATE INSTALLED 447. <br /> OR COATING 112.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINID <br /> Check one item and <br /> ❑99.OTHER <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC UNKNOWN 443. DATE INSTALLED 449. <br /> PROTECTION PROTECTION ❑4,IMPRESSED CURRENT ❑99.OTHER <br /> If A licablc 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED Oso, TYPE 451. OVERFILL PROTECTION EQUIPMENT:' YEAR MSTALLED 451. <br /> (Check 1 t ply) ❑1.SPILL CONTAINMENT I ALARM _ <br /> ❑2.DROP TUBE ❑2BALL FLOAT EI 3.FILL TUBE SHUT OFF VALVE <br /> . AT <br /> 3.STRIKER PLATE ❑4.EXEMPT <br /> IV.TANK LEAK DLT1 CTION <br /> (A,dcscriptiQn oF;the monitoring program shall be so lifted to,;tho"N'agency.). <br /> IF SINGLE WALL TANK 155 IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> (Checkall atapply) 454. <br /> UAL(EXPOSED PORTION ONLY) C35.MANUAL TANK GAUGING(MIG (Check ane❑I.VISUAL(inc.L( INSINGLE WALL M VAULT ONLY) <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG [17.GROUNDWATER ❑3,MANUAL MONITORING <br /> ❑4,STATISTICAL INVENTORY RECONCILIATION ❑g.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK.CLOSURE INFORMATION, / PER i[A7VENI T O�UILU:kp€�I r1� <br /> ESTIMATED DATE <br /> /LAST USED-YR/MO/DAY) 455. ESTIMATED <br /> rQUSAN"PITY OF SUBSTANCE REMAINING 106' TANK FILLED WITH INERT MATERIAL? <br /> ✓ll/1.(- �S' t.! gallons <br /> ❑Yes �a <br /> UPCF hwfwre-b(1/99).1/4 http://www.unidocs.org Rev.02/16/00 <br />