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6 t 41FIED PROGRAM CONSOLIDATED FORM TANKS 4 UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page-L-of " TYPE OF ACTION I.NEW PERMIT ❑ 4"AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 43o. (Check one item only) ❑ 3.RENEWAL PERMIT © 7.PERMANENTLY CLOSED ON SITE {Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NANM or DBA-Doing Business As) 3. FACILITY ID: I C-027- L44C 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# a3a. TANK MANUFACTURER 433. ' COMPARTMENTALIZED TANK ❑Yes No 434. �� «t'✓r41r1'� tDATELLED 435. TANK CAPACITY IN GALLONS 436. NUMI3ER QF COMPARTMENTS 437�L DESCRIPTION(For local use only) 436. II.TANK CONTENTS TANK-USE 439. PETROLEUM TYPE I. MOTOR VEHICLE FUEL 440. ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. !ET FUEL (Ifchecked,complete PetroteumType) ❑lb, PREMIUM UNLEADED �3. DIESEL ❑ 2. NON-FUEL PETROLEUM ❑ 1c. MIDGRADE UNLEADED ❑9 AVIATION GAS ❑a. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (&am}Iazardom Materials Inventory page) 441. CAS#(6nm Hazardous Materials Inventory page) 441. ❑ a. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER 2. DOUBLEOTHER WALL 4" SINGLE WALL IN A VAULT ❑95 THE OWN TANK MATERIAL- ❑99. OR primary 4snlc 1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 44, (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 118. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary ianlc ❑ 1. BARE STEEL 3. FIBERGLASS/PLASTIC 118. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) 112. STAINLESS STEEL 4. STEEL CLAD WIFIBERGLASS ❑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 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED 1199.OTHISR (Check one item ons ) � j OTHER CORROSION ❑ I.,MANUFACTURED CATHODIC I FIBERGLASS REINFORCED PLASTIC 95"UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ©99.OTHER IIA licable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 456. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLEDr,-3 452. (Check all that apply) I-S2.DPRrLL COBEAI]yMENT o 3 ad l"ALARM �-9-C4,,T 3.FILL TUBE SHUT OFF VALVEG�y, dr't+. C3 2.BALL FLOAT_ 4"EXEMPT 3.STRIKER PLATS ii a [ yT. ' t,Try IV. TANK LEAK 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) ❑ 1. VISUAL(EXPOSED PORTION ONLY) 115.MANUAL TANK GAUGING(MTG) [] I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2" AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE NOR-�CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7,GROUNDWATER ❑3.MANUAL MONITORING [:14. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V. TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMXrED DATE LAST USED(YR/MOiDAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http:liwww.unidocs.org Rev.02/16i00