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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE I (Two pages per tank) Page-L o{ Z TYPE OF ACTION ❑ I.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (meckom itemadY) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (SPaifitPaov) (SPCRi'�n) S.TANK REMOVED BUSINESS NAME(S..FACI.ITYNAME-DBA-W4 B-m M) 3. 1 FACILITYID: 1' 130w f-'Try f) P o er\ - LOCATION WITHIN SITE(Op.ep '31' - I..TANK DESCRIPTION - (ASCaled 0101 Tian with the location of the USTl system:nclumng loll gs and lam)mat ll submitted to the local agency.) TANK ID d +32 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK E]Yes No 434. V,ST 2 1 if Yee'Povine.PPgefiveerAwrcmnmt. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) /?S-0/Oz- 1SSo E,t 1- ADDITIONAL DESCRIPTION(F.mWvdr) �( 438. Tank Ohl YL V,, Cr ra'A II-TANK ' e � . TANK USE '39. PETROLEUM TYPE 416. 1. MOTOR VEHICLE FUEL (ala. REGULAR UNLEADED ❑2. LEADED ❑5. HET FUEL (Ifehrrked,.�lno Pevvlem'TY ) ❑lb. PRFMUMUNLEADED 03. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑d, GASOHOL ❑99.OTHER: ❑ 3. CHEMICALPRODUCT COMMON NAME (Eom Evvdove MatvWa lveonou PP) 441' CASH(fmm33amdoue Mata®hlnsmmry Pee) a62 ❑ 4. HAZARDOUS WASTE (IrJudo Usd Oil) ❑ 95.UNKNOWN d III.TANK CONSTRUCT['IM" TYPEOFTANK Q1. SINGLE WALL ❑3 SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one Hem only) MEMBRANE LINER ❑95. UNKNOWN [12. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER A. TANKMATER -pm®ryma KI. BARESTEEL ❑3. F®ERGLASS/PLASTIC I. CONCRETE 095.UNKNOWN 414. (Cb=k om item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [IS. FRP COMPATIBLE [199.OTHER: REINFORCEDPLASTIC FRP) W/100%METHANOL TANK MATERIAL-seeondary tank C]1. BARE STEEL 3. FIBERGLAS S/PLASDC ❑8. FRP C0mvDELE W/100%METHANOL 95.UNKNOWN aas. (Cheek one item only) [12. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRE'T'E TANK INTERIOR LINING 1.RUBBER LINED OX 3.EPDXY LINING 5.GI SS LINING 995.UNKNOWN 446. DATE INSTAt-I-ED 417. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINBNG ❑6.UNLINED ❑99.OTHER Cheek orc item od OTHER CORROSION 0 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED M9. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER fA Icable 2.SACRIFICIAL ANODE SPILL AND OVERFML YEAR INSTALLED 450. TYPE 451. OVP-RFILL PROTECTION EQUIPMENT: YEAR INSTALLED 451 (Cbeck all that apply) ❑1.SPILL CONTAINMENT ❑1.ALARM _ [13.FILL TUBE SHUT OFF VALVE [12.DROP TUBE ❑2.BALL FLOAT_ ❑4.EXEMPT 3 STRIKER PLATE -.- „ :TANK LEAKDETECTION "c. 4 . -.(A desar",Bof rye momtdrihg program shalLbe submined:to the locai.ageney14. IF SINGLE WALL TANK 45z IF DOUBLE WALL TANK OR TANK WITH BLADDER 451. (CLeck all that apply) (Cbeck one item Duly) 1.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)-BIENMAL TANK TESTING ❑99. OTHER V'TANK CLOSURE INFORMATIOi?, ESTIMATED DAIS LASTUSEU(YR/MO/DAY) 155' ESTIMATED QUANTITY OF SUBSTANCE REMAUUNGN 456' TANK FILLED WrrHINERT MATERIAL? /J-5- 45!' 1 Z/� /60 gallons [3 Y.. J No UPCF hwhrre-b(1199)-114 bttp://www.unidoes.org Rev.02/16100 0 •