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r UNIFIED P ROG RAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 .4e& D,C <br /> (Mo pages per tank) <br /> Page <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4. AMENDED PERMIT W, CHANGE OF INFORMATION) 0 8. TEMPORARY SITE CLOSURE <br /> (Check one item only) <br /> ❑J.RENEWAL PERMIT 0 T PERMANENTLY CLOSED ON SITE <br /> (Speciy mason-brlocalu»tow (Spocdy Gaps-brlonl use only) ❑ 8. TANK REMOVED 430 <br /> B SINESS NAME(Same as FACILITY NAME or DBA-Ocing Bees As) FACILITY ID a 1 <br /> ��1L H[K cu, 3�( 0 <br /> LOCATION WITHIN SITE�(OpGona4 431 <br /> 1.TANK DESCRIPTION wJ� <br /> TANK 104 TANK MANUFACTURER COMPARTMENTALIZED TANK D Yes JCKkIg, <br /> II'Yei,complete one page br each compartment. <br /> DATE INSTALLED EA O) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DRIPNON(Forbcal ask only) <br /> II.TANK CONTENTS <br /> TANK USE 432 zp PETROLEUM TYPE <br /> 00 1. MOTOR VEHICLE FUEL W�a. REGULAR UNLEADED ❑ 2, LEADED ❑ S. JET FUEL <br /> ll marked,complete Petmkpm Type) 0111 PREMIUM UNLEADED D 3. DIESEL 0 S. AVIATIONFUEL <br /> 0 2. NON-FUEL PETROLEUM 01c MIDGRADEUNLEADED 0 4 GASOHOL 0N.OTHER <br /> 0 3.CHEMICAL PRODUCT <br /> 0 4. HAZARDOUS WASTE(Includes COMMON NAME(lmm Hazardous Materials Imeorhrypage) CAS 4lhcm Nazutlous Matadals lnrenbrypage) <br /> Used 010 <br /> 0 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 0r-a�1 SINGLE WALL 0 3, SINGLE WALL VATK 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> ne <br /> (CheckottemonlyP <br /> ) °- DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 C SINGLE WALL IN A VAULT 0 99 OTHER <br /> TANK MATERIAL-phmary lank t. BARE STEEL 0 3, FIBERGUSS/PLASTIC 05. CONCRETE 095. UNKNOWN <br /> (Check.,$am only) ❑ 2. STAINLESS STEEL 0 4. STEEL CUD WIFIBERGUSS D 8. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC FRP) <br /> TANK MATERIAL-secondary tank 0 1 BARE STEEL 0 3. FIBERGLASSIPUSTIC D B. FRP COMPATIBLE W1100%METHANOL 1:195. UNKNOWN <br /> (Check one item only) 2. STAINLESS STEEL 0 4. STEEL CUD WIFIBERGUSS 09 FRP NON-CORRODIBLE JACKET 1:199. OTHER <br /> REINFORCED RUSTIC(FRP) 1110 COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1 RUBBER LINED 0 3. EPDXY LINING 05 GLASS LINING ❑95. UNKNOM433 OATE INSTALLED <br /> OR COATING <br /> ❑ 3. ALKYD LINING �. PHENOLIC LINING 138. UNLINED 1199. OTHER <br /> (Crack Dna item onl) (Fprbcal use Dory) <br /> OTHER PROTECTION <br /> IF ON � MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED RUSTIC 095. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> (Check one item only) ❑ 2. ❑ 4. IMPRESSED CURRENT D99. OTHER <br /> SACRIFICIAL ANODE lForlocal case only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE!For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) �1 SPILL CONTAINMENT - 1.ALARM D 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Checkak theta ): IF DOUBLE WALL TANK OR TANK WITH BUDDER!Check one item orW: <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) 0 S. MANUAL TANK GAUGING(MTG) D 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) 06. VADOSEZONE TEL CONINUOUSINTERSTITIALMONITORING <br /> ❑ 3. CONTINUOUSATG 0 Z. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR)4 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING 099, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PUCE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑Na <br /> CUPAFORM(4199) • • <br /> Formerly` CUPA <br />