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r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Two pages per lank) Page_of_ TYPE OF ACTION [I L NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Chak one bemoaly) ❑ 3.RENEWAL PERMIT ❑..��7.PERMANENTLY CLOSED ON SITE (Spooify town) (Specifyte Son) U-I ANK REMOVED BUSINESS NAME(5aas.FACB.ITY NAMEOIDBA-Dong ices All 3. FACILITY ID: 1. 74"9 S CO ALT Q LOCATION Wfl'FIIN SITE(Ogimw) 431. tr(J CD>zt?6 1.TANK DESCRIPTION (A scaled It plan with the location of the UST system including buildings and landmarks Shall be submitted to the local agency.) TANK ID# 43z TA534'a C) 'N 1K MANUFACTURER 433. COMPARTMENTALIZED TANK Yes No 434, N/U If"YM"mn4 eke om page for®ch mn9art . UAIEINSTALLED 435. TANK CAPACITY IN GALLONS 435. NUMBER OF COMPARTMENTS (YEAR/MO) 437. AD fl'ONALD SCRIPTION(Fmbcdmeody) 438 e-hTt uC>` L 11.TANK CONTENTS TANK USE 439. PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED440 (Ifch kegwMilte Petolemi Type) ❑2. LEADED ❑5. FUEL ❑Ib. PREMIUM UNLEADED [:13. DIESELAV❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL .OTHER: E' T),t�+ QIP ❑ 3. CIIBMICUCT COMMON NAME (aom Nmmdou Matmmislmemory page) 1' CAS#(fiom HavNous hlNg'vb lnvenbrypage) 4tZ ❑ 4. HAZARDOUSOUSWAWASTE (Iodladm used a0 ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL Cl 3. SINGLE WALL WITH EXTERIOR 135. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Cbeck one dem only) MEMBRANE LINER El 95. UNKNOWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-pmary tank . BARE STEEL ❑3. FIBERGLASS/PLASTIC (Chk om aem only) ❑2. STAINLESS STEEL ❑4, STEEL CLAD W/FIBERGLASS ❑5. CONCRETE 95.UNKNOWN aw ❑8. FRP COMPATIBLE ❑99,OTHER: REINFORCED PLASTIC FRP) W1100%METHANOL, TANK MATERIAL-secondary tank 1. BARE STEEL 3. FlBERGLASS/PLASTIC S. FRPCOMPTIBLEW/10UXMETHANOL U95.UNKNOWN 45. (Check one dem only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLAS$ [39. FRP NON ERODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑ ST 10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING Ll 5.GLASS LINING ❑95.UNKNOWN W. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING A UNLINED ❑99.OTHER (Check one Rem onl ) OTHER CORROSION 1.MANUEACTIJRED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 5.UNKNOWN 448. DATE INSTALLED N9. PROTECTION PROTECTION ❑4.IMPRESSED CURREN- ❑99.OTHER If liable ❑2.SACRIFICIAL ANODE SPILL ANDOVERFRL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTIONEQUfPMENT: YEARINSTAL[,ED 452. (Cheek all that apply) ❑1.SPILL CONTAINMENT ❑I.ALARM _ [13.FILL TUBE SHUT O F VALVE ❑2.DROP TUBE /I ❑2.BALL FLOAT_ ❑4.EXEMPT N ❑3.STRIKER PLATE T IV.TANK LEAK DETECTION (A description-1.1-monitoring program shall be submitted to the local agency.) ff SINGLE WALL TANK 453. 1F DOUBLE WALL TANK OR TANK WITH BLADDER 4X. C kal that apply) (Checkom hem only) VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑C VADOSE ZONE ❑2.CONTINUOUS INTERSTITIA,MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑4.STATISTICAL INVENTORY RECONCILIATION [3 3.MANUAL MONITORING ❑6.TANK TESTING (SIR)+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 456. TANK FILLED WITH INERT MATERIA,? 431 gallons ❑Yes [I No UPCF hwfwre-b(1/99)-1/4 httpJ/www.unidoco.org Rev.02/16!00