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L,3 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 �� °y Pk 5,;? 3 4a 9 (Two pages per tank) 0 -! Page_of_ Sv TYPE OF ACTION ❑ 1.NEW PERMIT (14.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE 7 i (Specify recon) (Specify recon) 8.TANK REMOVED e BUSINESS NAME(Serne se FACILITY NAME or DBA-Doing Business Ae) 3. FACILITY LOCATION WITHIN SI (opt m0 431. I.TANK DESCRIPTION (A scaled plot pian with Ole location of the UST.system including buildings and landmarks shill bosubmit(ed to the lucid agenc).) TANK ID# '707 433. TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes IS No 434. 0&'T - \ Uh kr ry h If'Yu,"wmpleteowpVeforechwmpanmon DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 43]. UP,K„oWn Goa (as+) one- ADDITIONAL neADDITIONAL DESCRIPTION(For local use only) 439, 11.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440 19 1. MOTOR VEHICLE FUEL IZ la REGULAR UNLEADED .9 2. LEADED ❑5. JET FUEL (Tfelecked,complde Penuleum Type) ®16. PREMIUM UNLEADED tA 3. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM 5&lc. MIDGRADE UNLEADED (14. GASOHOL ,klvv.OTHER: (/(�L(�YL.l.7J ❑ 3. CHEMICAL PRODUCT COMMON NAME (6om Haurdous Mderiele lu.nspry page) 441' CAS#(Born Hemdous Materiels Inveraory page) 442 ❑ 4. HAZARDOUS WASTE (Indudea used oil) ❑ 95.UNKNOWN TIT.`CASK�'�M1�STRTICTIDI�1 TYPE OF TANK Pr I. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WRH INTERNAL BLADDER SYSTEM 443. (Check one item ordy) MEMBRANE LINER ❑95. UNKNOWN Ll 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primaryterk ®-I. BARE STEEL 3. FIBERGLASS/PLASTIC Ll 5. CONCRETE L3 95.UNKNOWN 444. (Check one itemaNy) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE [199.OTHER: REINFORCEDPLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank L BARE STEEL 3. FIBERGLASS/PLASTIC 8. PRP COMPTIBLE W/100%METHANOL CI 95.UNKNOWN 445. (Clock one hem only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY LINING 0 5.GLASS LINING 19 95.UNKNOWN 446. DATE INSTALLED M7. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED [199.OTHER Check one iremod OTHER CORROSION Ed L MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 9 95.UNKNOWN 448, DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99,OTHER Of Applicable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM -❑3.FILL TUBE SHUT OFF VALVE_ ❑2.DROP TUBE _ ❑2,BALL FLOAT_❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to ilio 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) CI5.MANUAL TANK GAUGING( ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) [16.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUND WATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION [3 S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99,OTHER K CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTI DATE LAST USED(YR/MO/D Y) ass. ESTIMATEDQUANTITYOFSUBSTANCEREMAINING 456. TANK t7LLED WITH INERT MATERIAL? 457. .a gallons ❑Year ❑ No UPCF hwfwm-b(1/99)-1/4 h@p://www.unidoa.org Rev.02/16/00