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UNIFIED PROGRAM CONSOLIDATED FORM / <br /> q <br /> TANKS RUIIIXZAI <br /> 7 <br /> UNDERGROUND STORAGE TANKS- qG _7 <br /> nWyPaBepcnWc) 9� <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT <br /> l Page-of <br /> (C'heck one itemaNr) ❑ 3.RENEWAL PERMIT <br /> ❑ 3.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE np, <br /> ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify'.. .) (Specify ❑ S.TANK REMOVED <br /> BUSINESS NAME(s..FAOuxryNAME. BA- Business As) 1 FACILITY ID: <br /> l <br /> LOCATION W�TlTHIN SITE(ov6ana0 .r <br /> 431. <br /> L TANKDESCRIPTION - - <br /> (A scaled lot lapi wtI the location ofthe UST system including.buildings ad III shall he submitted to theJocal,agene:) <br /> TANK ID# 41 TANK MANUFACTURER u3. <br /> T COMPARTMENTALIZED TANK Y No 434. <br /> ��F��W If"Ye;'mmpleie one pelt-for each m"..nl <br /> DATE NST LED 4" TANK CAPACI-IY IN GALLONS 434 <br /> (YEAR/MO) (r !�/L NUMBER OF COMPARTMENT$ <br /> v�(�l� �/ JO 437. <br /> ADDITIONAL DESCRIPTION(For 1«�rue only) <br /> 439. <br /> II.TANK CONTENTS <br /> TANK USE 434 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑l ❑ ��'///a. REGULAR UNLEADED 2. LEADED 440. <br /> ❑5JET �1a�' <br /> ([(checked,mmplde PetmleumType) . FUEL❑Ib. PREMIUM UNLEADED <br /> ❑3. DIESEL ❑6. AVIATION GAS ee qq )) <br /> K2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED El 4. GASOHOL ❑99.OTHER:_�C/LD�£/l/� <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om 14urdom Mocaals Invent 44L <br /> ❑ 4. HAZARDOUS WASTE '/ rypo�e) CAS#(6am Hvudous MaeridslnwuorypVe) 443. <br /> (Include Beed Oil) {� e2 ep 1[" <br /> ❑ 95.UNKNOWN !� LN <br /> IIL TANIK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL " <br /> (Ch«k one item oily) ❑3. SINGLE WALL WITH EXTERIOR ❑5 SINGLE WALL WITH INTERNAL BLADDERSYSTEM 443. <br /> MEMBRANE LINER ❑95. UNKNOWN <br /> ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary imk L BARE$TEFL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE <br /> (Ch«k one sem only) ❑2. STAINLESS$TEFL ❑4. STEEL CLAD W/FIBERGLASS ❑95.UNKNOWN 444. <br /> ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> TANK MATERIAL- REINFORCED PLASTIC W/100°4 METHANOL <br /> secondary u� ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC B. FltP GDMPTIBLE W/100%METHANOL 95.UNKNOWN 445. <br /> (Ch«k ane itam only) ❑2. STANCES$STEEL ❑4. STEEL CLAD W/FIBERGLASS 9. FRP NON- <br /> ❑ CORRODABLEJACKET ❑99,OTHER <br /> /� A REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> TANK INTERIOR LINING 5. CONCRETE <br /> k.RUBBER LVED 3.EPDXY LINING GLASS LINING 95.UNKNOWN <br /> OR COATING C 2.ALKYD LINING ❑4.PHENOLIC LINING $6.UNLINED 446. DATE NSTALLEO kale <br /> Ch«k one item oN / ` ❑99.OTHER <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC J 3.FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION PROTECTION ❑95.UNKNOWN 44fl. DATE STALLED 449. <br /> IF lieeble 2.SACRIFICIAL ANODE ❑4.IMPRESSED CURRENT ❑99.OTHER <br /> SPIL S01VERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALL D 451. <br /> (Check all that apply) ❑1.SPILL CONTAINMENT ❑1 ALARM <br /> ❑2.DROP TUBE ❑3.FILL TUBE SHUT OFF VALVE <br /> ,.STRIKER PLATE �/f ❑2.BALL FLOAT_ ❑4.EXEMPT - )/ <br /> IV.TANK LEAK DETECTION <br /> A description of the monitoring program shall be submi4ed to the.local agenc .) <br /> IF SINGLE WALL TANK 453 IF DOUBLE WALL TANK OR TANK WffH BLADDER <br /> (Check all that apply) 454. <br /> ❑1. VISUAL(EXPOSED PORTION ONLY) (Check one item only) <br /> ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATC) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING <br /> [13. CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING <br /> ❑4.STATISTICAL INVENTORY RECONCILIATION ❑6.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑gg, OTf1ER <br /> V.TANK CLOSURE INFORIYIATION<! PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST US (YRMIO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 156' TANK FILLED WITH INERT ATFRIAL9 41f. <br /> - gallow ❑Yes No <br /> UPCF hwfwm-h(1/99).1/4 hltp://www.unidocs.org Rev.02/16/00 <br />