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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1I II wo pages per mak) Page_of_ t TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK11 SURE 430. (Chet orc ban only) ❑ 3.RENEWAL PERMIT ❑..,�7.PERMANENTLY CLOS-01 SITE (SPoolfy rason) (Specifyraaon) 9.1 ^ TANK REMOVED BUSINESS�N'AAa a NAME FACILIME Ty NAor DBA-Dong BmiMS As) 3. N FACB.ITY ID: I. Av yu1XJ OCE(oge LATION WITHIN SITE(Obnamt)O 431 W I.TANK DESCRIPTION (A scaled plot plea with the location of the UST system including buildlgs and landmarks shall be submitted to the local agency.) TAN}K�11)# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANTO Yes No 434. N•�K IfWa,"mrrylue orepege breach wngaumn. DATEINSTALLED 435, TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437. k NIeA.J ZO(i(!D 6 JU 6 ADDITIONAL DESCRIPTION(For boot use only) 438 S-A 0)1- II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. ❑ 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED [IS. lEI FUEL (H.h.k4 ronPlete Petrokan Type) ❑Ib. PREMIUM UNLEADED 03. DIESEL C1 6. AVIATIONG ❑ 2. NON-FUEL PETROLEUM [Ito. MIDGRADE UNLEADED [14. GASOHOL [lIB9.OTHER: ftEmra ❑ 3. CHEMICAL PRODUCT COMMON NAME (fiom Flvallom Mvenele lmenlorypaa) 441. CASH(6om Haw4om Muerelalwa4orypage) 442. ❑ 4. HAZARDOUS WASTE (hc6 Uaed all ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK INGLE WALL ❑3. SINGLE WALL WITH EXTERIOR [3 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one nem only) MEMBRANE LINER ❑95. UNKNOWN [12. DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-pbmrytook BARE STEEL El 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Chat on ban only) [12. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: KENFORCEDPLASTIC FRP W/I00%METHANOL TANK MATERIAL-m=dmy Ink ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL Ej 95.UNKNOWN 445. (Check on hem only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGIASS E19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING C3 S.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING X UNLINED ❑99.OTHER (CM1eck one item oN OTHER CORROSION 0 1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC .UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER (If Applicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Check all that apply) [11.SPILL CONTAINMENT [11.ALARM [13.FILL TUBE SHUT OFF VALVE_ [12.DROP TUBE AJ/A [12.BALL FLOAT_ ❑4.EXEMPT t 11 ❑3.STRIKER PLATE //llA IV.TANK LEAK DETECTION (A description of the monitoring pmgmm shall be submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 45a. ( k ell that apply) L VISUAL(EXPOSED PORTION ONLY) C35.MANUAL TANK GAUGING (Check one dem only) (MTG) ❑1.VISUAL(SINGLE WALLIN 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 ❑S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE �'_LAST USED OgUMO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. `{,C3 gallows ❑Yes ❑ No UPCF hwfwm-b(1/99)-1/4 http://www."idms.oil Rev.02/16/00