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1 � 1 UNIFIED PROGRAM CONSOLIDATED FORM TANKS -rii-D 5) UNDERGROUND STORAGE TANKS - TANK PAGE 1 &_9?5GD (Two pages per tank) Page of a TYPE OF ACTION 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 F"-,TMP-,RNA E(Same as FAr(LITY NAME or DBA-Doing Business As) 3. FACILITY ID: n� - . 0 R Tk,tl L 3 I. LOCATION WITHIN SITE(Optional) 431. I.TANK DESCRIPTION (A scaled plo Ian with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# TANK MANUFACT�JRER 433. COMPARTMENTALIZED TANK ❑ No 434 S '� •' ��fij I\Gi ❑Yes If"Yes,'complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS `'EA T,- Ivy' u o 0 2 437, ADDITIONAL DESCRIPTION(For local use only) 43s. II.TANK CONTENTS TANK USE 439. I hyj OLEUM TYPE t� I. MOTOR VEHICLE FUEL ,�/ 440. a. REGULAR UNLEADED ❑2. LEADED EI 5. ]ET FUEL (Ifcher complete Petroleum Type) 1 PREMIUM UNLEADED JW. DIESEL ❑6. AVIATION GAS El 2. NON-FUEL PETROLEUM lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Invento 4417 Inventory page) CA$#(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 ❑95. UNKNOWN OUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. TEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE REINFORCED PLASTIC FRP W/100%METHANOL El 99.OTHER: TANK MATERIAL-secondary tank ❑I. BARE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL (Check one item only) :195.UNKNOWN 445. ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑5. CONCRETE OR COATING ❑3.EPDXY LINING ❑ .GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. ❑2.ALKYD LINING ❑4.PHENOLIC LINING 6.UNLINED ❑99.OTHER Check one item onl OTHER CORROSION ❑1.MANUFACTURED CATHODIC M3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN aae. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT If A licable ❑2.SACRIFICIAL ANODE ❑99.OTHER SPILL AND OVERFIL YEAR INSTALLED 450. TIE"a51. O RFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT 40}�ALARM 2.DROP TUBE Q'2.BALL FLOAT_ ❑4.FILL TUBE SHUT OFF VALVE_ STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING MTG (Check one item only) ( ) ❑11 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE EJ 2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [:18.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.unidocs.org Rev.02/16/00