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/f p low UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page Z of Z TYPE OF ACTION L 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 BUSINESS NAME(same av FACILITY NAME orD13A-Doing Business As) 3. 1 FACILITY ID: 77 LOCATION WITHIN SITE(Optional) 431. L 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# 432. TANK MANUFACTURER 433• COMPARTMENTALIZED TANK ❑Yes No 434. e-oN`T4/rlr gd r ( '7 t<) If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2CIDrj D 201 oo c, ADDITIONAL DESCRIPTION(For locai use only) 498. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440, I. MOTOR VEHICLE FUEL via. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked.complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. 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 ❑95. UNKNOWN It_ 2. DOUBLE WALL [:14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primacy tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑ 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WJFIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING 5.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one item only) zLY.J OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 443. BATE INSTALLED 449_ PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (IfApplicable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450, [TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED c-i 452. _ (Check all that apply) 1.SPILL CONTAINMENT O 1.ALARM V-K�_ g3.FILL TUBE SHUT OFF VALVE CInL 2.DROP TUBE o= �7s,w ❑2.BALL FLOAT U 4.EXEMPT 3.STRIKER PLATE .1V L ,s►'1� IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALT,TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG [37.GROUNDWATER 3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TEST[`i 7G ❑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 hwfwre-b(1199)-1/4 http://www.unidoes.org Rev.02/16/00