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UNIFIED PROGRAM CONSOLIDATED FORM TANKS �1 D7 UNDERGROUND STORAGE TANKS - TAN G 1 ( ^}/�71(�}7� IB�JJ ( 4Z (T� P " Iyer tank) TYPE OF ACTION I4-� Of_ EW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFO U Pa (Chat one immonlY) ❑ 3.RENEWAL PERMIT 6.TEMPORARY TANK CLOSURE no. ❑ T,PERMANENTLY CLOSED ON SITE BUSINESS NAME same vFA (g B.jaa roe) (9palfymaann) ( C8.r1'Y NAAff or DBA-Dom Business A< J. FACILITY ID: t,) ❑ S.TANK REMOVED L' a9CrJnJ � d 2sy ) ^:;I LOCATION WITHIN SITE(opooma '.Y• I.7f 431. I;TAN&DESCRIPTION seated lOt 1 43 �)ocati h theon.ofthe UST .,I,eJRinclgdin buildiO d,lanamarksshalLibe ub Itted;zo t e l 1, TANK ID q 45z1TANK MANUag FACTURER - h .OFA- Ben.. :) u1 COMPARTMENTALIZED TANK Yes NO 454. DATE IN TILLED 455. TANKCAPACITY IN GALLONS 456. Jt•Ye;'wmplme one p.ge for e.0 wmp.n,,,.nt (YEAR/MO) � _ // NUMBER O F COMPARTMENTS 6i / - 437. ADDITIONAL DESCRIPTION(For bcH um only) Ue. u9, .Ii -t TANK USE PETROLEUM TYPE ❑ I, MOTOR VEHICLE FUEL �E (Ifa ld,wmplve Pvmkum TYpe) ❑la. REGULAR UNLEADED ❑2. LEADED - 440. ❑Ib. PREMIUM UNLEADED ❑S. AVIET ATION ❑ 2. NON-FUEL PETROLEUM ❑3. DIESEL [16. AVIATION GAS'/ ,7 r ❑lc MIDGRADE UNLEADED ❑4, GASOHOL ❑99.OTHER: R f,rBfF/l/ ❑ 3. HAZARDOUS WASTE COMMON NAME 6om HuardomMakrials lnvwlo 441. ❑ 4. HAZARDOUS WASTE ( rYPeae) CASk(from Hazardous Materials lnage) 441 (Include Wad Oil) -tery 5.UNKNOWN ppl�yy TYPE OF TANKIZe (Check one item oalY) 1. GLE WALL ❑3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER ❑S. SINGLE WALL WITH INTERNAL BLADDERSYSTEM ,4u. DOUBLE WALL 4. SINGLE WALLIN A VAULT 095. UNKNOWN TANK MATERIAL_primvy tank . BARE STEEL 99. OTHER (Check mu item only) ❑3' STEEL LA D W/FI STIC ❑5. CONCRETE ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/P1B 'KNOWN 444. EC(II ❑8. FRP COMPATIBLE TANK MATERIAL_secondary Ards 1. BARE STEEL REINFORCED PLASTIC RP W/1 GOY.METHANOL ❑99.OTHER' (CII one item only) 3. FIBERGLASS/PLASTIC S. FRPCOMPIIHLEW/100`%METRA ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET UNKNOWN 445. REINFORCED PLASTIC(FRP) ❑10. COATED STEEL -OTHER TANK INTERIOR LINING 4.RUBBER LINED ❑5. CONCRETE OR COATING 3.EPDXY LINING 5.GLASS LMMG Cheek one item ool ❑2'ALKYD LIMNG ❑4.PHENOLIC LINING ❑6.UNLINED 95'OTHER 446. DATE INSTALLED 44]. OTHER CORROSION ❑99.OTHER ❑1.MANUFACTURED CATHODIC PROTECTION PROTECTION ❑3.FIBERGLASS REINFORCID PLASTIC 5,UN OWN 448. DATE INSTALLED 449, If A IiND 2.SACRIFICIAL ANODE ❑4'IMPRESSED CURRENT ❑99.OTHER SPILLANDOVERFILL YE INSTALLED 450TYPE 4s1. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 452. (Cheek all that apply) ❑1.SPILL CONTAINMENT ❑2.D BIKER PL ❑I.ALARM ._a �y FILL TUBE SHUT OFF VALVE_ 3.STRIKER PLATE ❑2.B914LjEL�C�� tom\.EXEMPT IV.TANK LEAK DETECT107V IF SINGLE WALL TANK (A doscrJ tlOmoMoynomtonng program shall be subms ed tp thbloca)ageea (Chock all that apply) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING MTG (Chwk one item ody) ❑2.AUTOMATIC TANK GAUGING(ATG) �}R ( ) 01,VisUAL(SINGLE WALL M VAULT ONLY) ❑3.CONTINUOUS ATG ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑T W NI'E ❑4,STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING ❑3.MANUAL MONITORING (SIR)+BIENNIAL TANK TESTING E)99. OTHER V.TANT{,C[OSiiRE`I VFORMA T 70N/ 1T] ESTIMATED DA TUSED(y R/MO/DAY ��U77N PI•,ACE.. rV) ) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT,MATERIAL7 457. gallons ❑Yea o UPCF hw[wrnb(1199).1/4 httP://www.unidoes.org Rev.02/16/00