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13 UNIFIED PROGRAM CONSOLIDATED FORM TANKS c UNDERGROUND STORAGE TANKS- TANK PAGE 1 s�I ��° ai 3 a / (Two pages per tank) 0T Page_of_ V 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 �t (Specify re..) (Specify reason) 8.TANK REMOVED e BUSINESS NAME(Smne ae FACILITY NAME or DBA-Doing Buemers As) 3. FACILITY u�, 1. s 's �l r F /7 15 c� 3 LOCATION WITHIN SI E fops ref) 43114 _l 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# '757 432 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes C5 No 434 US'T- \ Un If r If'Yee,complete one pageto,eachcompere.t. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) V31Kno4„n ADDITIONAL DESCRIPTION(For low we only) 439. II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440. $( 1. MOTOR VEHICLE FUEL 1Z In. REGULAR UNLEADED $2. LEADED [IS. JET FUEL (If checkd,compine Peaoleum Type) ®lb. PREMIUM UNLEADED J13. DIESEL ❑6. AVIATION GAS [1 2. NON-FUEL PETROLEUM 53 to. MIDGRADE UNLEADED ❑4. GASOHOL OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (8rom Hacodow Materials Inventory page) 441. CAS#(from Humdmm Metenah Inventory page) 441. ❑ 4. HAZARDOUS WASTE (Includes UsM Oil) ❑ 95.UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK Pr I. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primuy look I I. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Chmk one itemonly) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank [11. BARE STEEL 3. FIBERGLASS/PLASTIC N. FRP COMFTTBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS [19. FRP NDN-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED 3.EPDXY LINING Ll 5.GLASS LINING 95.UNKNOWN W. DATE INSTALLED 447. OR COATING [12.ALKYD LINING [14.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one item onl OTHER CORROSION 1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 9 95.UNKNOWN 449. DATE INSTALLED 449, PROTECTION PROTECTION El 4.IMPRESSED CURRENT [199.OTHER If livable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTTONEQUIPMENT: YEAR INSTALLED 452. (Check all that apply) [It.SPILL CONTAINMENT [11.ALARM [13.FILL TUBE SHUT OFF VALVE_ [12.DROP TUBE ❑2.BALL FLOAT_❑4.EXEMPT [13.STRIKER PLATE 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) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER _ K CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTTM. DATE LAST USED(YR/MO/D Y)� 055' ESTTMATEDQUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL? 45Z P gallons ❑Yes ❑ No UPCF hwfivrc-b(W9).114 hep://www.unidoo.org Rev.02/16/00