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0 UNIFIED PROGRAM CONSOLIDATED FORM TANKS 51593 Z' UNDERGROUND STORAGE TANKS - TANK PAGE 1 PC;-3Sv (Two pages per tank) oe Page-3-of TYPE OF ACTION 70 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUS E S NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: 1. WAM u�Lsu 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 ID# 2 I ` h/4 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434. C-/)S 1, 7 `t_✓ ,J O ?- If"Yes;'complete one page for each compartment. DATE INSTALpLED p` 435. TANK CAA,P,ACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEA"O) L�✓U '✓fM�' 21 437, ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TAAIK USE 439 PETROLEUM TYPE 44II 'f1. MOTOR VEHICLE FUEL '�%REGULAR UNLEADED �❑//2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) IIIb. PREMIUM UNLEADED '1'3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM EvIc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) �/ MEMBRANE LINER C395. UNKNOWN u DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL -03. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS E-18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑ I. BARE STEEL V3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑,,YY GLASS LINING El 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING El 4.PHENOLIC LINING �6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 449. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFIL,,L,,,,,,(( YEAR INSTALLED 450. YP r 451. F2. FILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT vuo. ALARM 0 3.FILL M.DROP TUBE BALL FLOAT ❑4.EXEMPT E SHUT OFF VALVE 3.STRIKER PLATE IV.TANK LEA&DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑ VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) �J 2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [:17.GROUNDWATER ❑3.MANUAL MONITORING [14.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfWrc-b(1/99)-1/4 www.unidoes.org Rev.02/16/00