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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT (Chxk. ksmaW ❑ 3. RENEWAL PERMIT (SPeaM'rssaon - MMeal uv afkYl ❑ S. CHANGE OF INFORMATION) (SPacily4rvga-a:YIO vm.aYf TANKS (hWI Pages per tank) Page _ OI ❑ S. TEMPORARY SITE CLOSURE ❑ T. PERMANENTLY CLOSED ON SITE n BUSINESS NAME (Some as FACILITY NAME or DBA - Ddnp Buau»sa Aal FAGUTY ID -. ................. �.. ...,, 1 LOCATION WITHIN SITE(Opkowa 431 1. TANK DESCRIPTION TANK IDR TANK MANUFACTURER COMPAgTMENTAU2EDTANK Yee ❑ N. II'Yee', complete one page M asrJl Compaamem. DATE INSTALLED(YEARIMO) TANK CAPACITY INGALLONS NUMSEROFCOMPARTMENTS 0000 f-,ctlON-t Cf ADDITIONAL DESCRIPTION (ForWal u» pnIK IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE W"MOTOR VEHICLE FUEL ,/ M . REGULAR UNLEADED ❑ 2. IFADEO ❑ 5. JET FUEL (emadW, conpmb Pahobwn Type) ❑1I1. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL ❑ 2. NON-FUELPUM ClMIWRADEUNLEAOED 1�"_ ` ❑ 4. W$OHOL ❑99. OTHER 11 3. CHEMICALPRODUCT COMMON NAME (hom Haaaa oua MelenWs Inve goW,Ipe) CAS a (ftm Haaaalous Maf ,,Mls lnvenfarypage) ❑ 4. HAZARDOUS WASTE Ik Ielas Uead Go) 95 UI III. TANK CONSTRUCTION TYPE OF TANK 1 SINGLE WALL Cl 3. SINGLE WALL WITH ❑ 5. SINGLE WALL NRH INTERNAL BLADDER SYSTEM (Chock Omkemor,W U -T DOUBLE WALL EXTERIOR MEMBRANE LINER [IN UNKNOVIN ❑ 4. SINGLE WALL IN A VAULT ❑98. OTHER TANK MATERIAL -pNnmY tank 11 1 BARE STEEL 3. FIBERGLASS I PLASTIC 115. CONCRETE 1196. UNKNOWN �❑ ck (Cheam Mom Orly) ❑ 2, STAINLESS STEEL 01 STEEL CLAD WIFIBERGLASS ❑ B. FRP COMPATIBLE Wll0 METHANOL 1199. OTHER REINFORCED PLASTIC (FRP) FIBERGLASSIPLASTIC El B. FRPCOMPATIBLEWIIW%METHANOL 1195. UNKNOWM TANK MATERIAL - secondary lank C] 1 BARE STEEL❑I��1 �3. (Oheckorm9am OJy) ❑ 2. STAINLESS STEEL We' STEEL CIAO WIFIBERGLASS ❑ 9. FRP NON -CORRODIBLE JACKET 0 . OTHER REINFORCED PLASTIC (FRP) [1 10. COATED STEEL ❑ S. CONCRETE LINING 0 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING UNKNO TA COATING ❑95. WMa33 GATE INSTALLED OR COATING �I/ 0 2. ALKYD LINING 11y 4. PHENOLIC LINING p. UNUNED ❑N. OTHER (Chock mm demo Forbcal vaso OTHER PROTECTION IF ON PROTECTION IF APPLICABLE 13 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATEINSTALLED PROTECTION ❑ 4. IMPRESSEDCURRENT ❑ 99. OTHER (Chock Oro dam only ❑ 2, SACRIFICIALANODE (Fwgpl we Onlli SPILLANOOVERRLL YEAR INSTALLED TYPE (FOrkxaluaea*) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 938 6 (Check M fhot appy/ ❑ L SPILL CONTAINMENT / 111. ALARM QA FILL TUBE SHUTOFF VALVE ❑ 2. DROP TUBE _ ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE V. TANK LEAK DETECTION IF SINGLE WALL TANK CheckM" IF DOUBLE WALL TANK OR TANK WITH BLADDER Check mm item on ❑ 1, VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSE ZONE 112. CONTINUOUSINTERSTITMLMONITORING D3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICALINVENTORYRECONCILIATION(SIR)♦ ❑ a, TANKTESTING BIENNIAL TANK TESTING 11 os, OTHER V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED ryfvmo DAY) ESTIMATED QUANTITY OFS BSTANCE REMAINING 435 TANK FILLED VATH INERT MATERIAL? A- XA4 , geko a ❑ Yea ❑ Na CUPAFORM (4199) , ea, *r/ FormBAy SARCS Farm B