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73 UNIFIED PROGRAM CONSOLIDATED FORM 1 TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 �dZ� 7/0 y Pk Jr ai 3 a g` (Two pages per tank) I Page_of_ TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chock one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify noon) (specifyS.TANK REMOVED e BUSINESS NAME(Smass FACILITYNAME or DDA-Doing Buaness M) 3. FAC)ITY; : I. °q 0� LOCATION WITHIN SI E(opt na) <3l \Q� I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the locale..agency.) TANK U)# '707 432. TANK MANUFACTURER 433, COMPARTMENTALIZED TANK ❑Yes 13 No 434. US*T- ` um Dnp h Yes;'tample a one page for a h wmpu m m. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. UnKnou'v% one- ADDITIONAL DESCRIPTION(Far lain me only) 4311 II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 40. $1 1. MOTOR VEHICLE FUEL Cff Is. REGULAR UNLEADED )9 2. LEADED ❑5. JET'FUEL (Mchecked.tampion,Petroleum Type) ®It PREMIUM UNLEADED 513. DIESEL El 6. AVIATION GAS /J ❑ 2. NON-FUEL PETROLEUM ER Ic. MIDGRADE(UNLEADED ❑4. GASOHOL OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (ham Flamdam Maternal:Inventory page) 441. CAS#(Gum Ha nadow Matenas inventory page) 442. ❑ 4. HAZARDOUS WASTE (tooled.Uaed oi0 ❑ 95.UNKNOWN III.TANK CONSTRUCTION' TYPE OF TANK L SINGLE WALL [13. SINGLE WALL WITH EXTERIOR [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check am item only) MEMBRANE LINER [195. UNKNOWN ❑2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99, OTHER TANK MATERIAL-pdmeryuN �1. BARE STEEL El 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100 METHANOL TANK MATERIAL-secondary lank [3 1. BARE STEEL U 3. FIBERULAS U S. FRP COMFTIBLE W/10U%METHANOL [3 95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED Ll 3.EPDXY LINING 5.GLASS LINING 19 95.UNKNOWN W. DATE INSTALLED 441. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION 1.MANUFACIVRED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC 99S.LwKNOWN 4411. DATE INSTALLED 449. PROTECTION PROTECTION [I4.IMPRESSED CURRENT [199.OTHER ITA liwble [12.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. 1 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE_ [12.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.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) ❑5.MANUAL TANK GAUGING(MTG) ❑T.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG [17.GROUND WATER [13.MANUAL MONITORING [14.STATISTICAL INVENTORY RECONCILIATION [19.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTI DATE LAST USED(YR/MO/D Y) 455. ESTIMATED Q)UANTITY OF SUBSTANCH REMAINING 454- TANK FILLED WITH INERT MATERIAL? 457. a �`gallons ❑Yes ❑ No UPCF hwfwre-b(IN9)-1/4 http://www.unidoo.org Rev.02/16/00