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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I B 117 (Two pages per tank) e_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 438. (Chwkmw,man wy) ❑ 3.RENEWAL PERMIT ❑3 7.PERMANENTLY CLOSED ON SITE (Specify rtmn) (Specifyrt n) 9a.tANKREMOVED 1\ BUSINESS NAME(Surcm FALum NAME-,DBA D67 lk3"M) 3. 1 FACILI'T'Y ID: Al 0 LOCATION WITHIN SITE(optinw) 431. W � 6 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the locale en TANK ID p 431 TANK MANUFACTURER 433. g �) II'' COMPARTMENTALIZED TANK Yes No 434. UA) V"Yq"mrrymteorotgeforeerE wmpartmvp. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 9 / ON6 437. ©o AD ITONALD SCRIPTION(Formduseody) 438. Eh rt uG. L II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ❑ L MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (Ifdrkedmmpk,lRwolamiTYpe) ❑lb. PREMIUM UNLEADED [3 3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MID TRADE UNLEADED ❑4. GASOHOL W-9.OTHER: E TJ Ax OIC, ❑ 3. CHEMICALPRODUCT COMMONNAME(fiomHammus Mnervle Maaoryptae) 1. CASA(6omHmndou Mmewslnvmlarypege) 441 ❑ 4. HAZARDOUS WASTE (mcled®Used 070 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK IML SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 4477 (Check one hem only) MEMBRANELINER 095. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL INA VAULT 99. OTHER TANKMATERW.-prmmymk . BARE STEEL ;, FIBERGLASS/PLASTIC ❑5. CONCRETE [3 95.UNKNOWN 494. (CAerkorohemonly) 02. STAINLESS STEEL [3 4. STEEL CLAD W/FIBERGLASS 118. FRP COMPATIBLE 099.OTHER: REINFORCED PLASTIC W/I00%METHANOL TANK MATERIAL-secoadary tank OLBARESTEEL 3. FIBERGLASS/PLASTIC U 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445. (Check one hem ody) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [715. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED U 3.EPDXY LINING 0 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING A.UNLINED ❑99.OTHER (Check one it..od ) OTHER CORROSION L1 I.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 5.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99. OTHER It' Erabk 112.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 451. (Cheek all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM _ ❑3.FILL TUBE SHUT O VALVE [12.DROP TUBE /I ❑2.BALL FLOAT_ ❑4,EXEMPT J.STRIKER PLATE T IV.TANK LEAK DETECTION (Adescriptionoftharmanitormg progrem shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. LChSpkelt that apply) (Checkooehemody) VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING INTO) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATO ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIB)+BIENNIAL TANK TESTING 099.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 436. 1 TANK FILLED WITH INERT MATERIAL? 457' Plbm ❑Yes ❑ No UPCF hwfwm-b(1/99).1/4 http://www.unidocs.org Rev.02116/00