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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages pec tank) <br /> Page---V of <br /> 4.AMENDED PERMIT ❑5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430, <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ ❑ PERMANENTLY CLOSED ON SITE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 8.TANK REMOVED <br /> (SP�y euson) (Specify rescan) 1. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business�) 3. FACILITY ID: <br /> _ 1 ( � O 431. <br /> Tr L r-- ��A n- a <br /> LOCATION WITHIN SITE bon.) M C ' <br /> b C <br /> L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and33attF <br /> 'ART eMbNTAi�tl�TRK Y s) No 434, <br /> TANK ID# 43z. TANK MANUFACTURER <br /> "complete one page for each compenm®t. <br /> l� a36- BER OF CONFAB"Ctvfl NTS 437. <br /> DATE INSTALLED 435 TANK CAPACITY IN GALLONS <br /> �..1.-11 ►� 43g. <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> II.TANK CONTENTS <br /> 440. <br /> TANK USE 439, PETROLEUM TYPE <br /> ® 1.MOTOR VEHICLE FUEL N la REGULAR UNLEADED ❑2. LEADED ❑5- JET FUEL <br /> (If checked,complete petroleum Type) 0 lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS <br /> ❑ 2. NON-FUELPETROLEUM EtTM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99 OTHER _, <br /> 441. CAS#(from Hazardous Materials 1nvanory page) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials t"a"y page) <br /> ❑ 4_ HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑ 95.UNKNOWN <br /> III.TANK CONSTRUCTION 443 <br /> TYPE OF TANK ❑L SINGLE WALL ❑3' S��R N�ELEN H£X LERIOR ❑95 SUNKNO WITII[N TERNAL BLADDER SYSTEM <br /> WN <br /> (Check one item only) 4. SINGLE WAIL IN A VAULT ❑99. OTHER 444_ <br /> ®2. DOUBLE WALL ❑ 5. CONCRETE 95.UNKNOWNTANK MATERIAL_-Primary tank 8-1. BARE STEEL <br /> 3. FIBERGLASS/PLASTIC❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FBERGLASS ❑ W/I99.OTHER: <br /> 00"/METHANOL <br /> (cCOMPATIBLE ❑ <br /> heck one item only) <br /> REINFORCED PLASTIC 95. <br /> TANK MATERIAL-secondary taolc ❑2.B AIMLESS STEEL❑4. SITEEL CLAD W/FBERGLASS ❑9-FRP NOOTpRROD LE /ABLE JACKET OL ❑99.OTHER_ <br /> WN aas. <br /> (Check one item only) REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑5- CONCRETE 446. DATE INSTALLED 447. <br /> T CR OI TE IOR LINING [12.ALKYD LINING ❑4.PHENOIILINING <br /> C LINING ❑6.-GLASSE55-5 <br /> G ❑99.OTHEROWN <br /> Check one item on! CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN <br /> a49. DATE INSTALLED 449. <br /> OTHER CORROSION ❑1.MANUFACTURED ❑4.IMPRESSED CURRENT ❑99.OTHER <br /> PROTECTION PROTECTION <br /> A livable ❑2.SACRIFICIAL ANODE <br /> 52- <br /> ALARM <br /> SPILL AND OVERFILL YEAR INSTALLED 450. TYPE asl. OVERFILL PROTECTION EQUIPFIMELL TU}LE SHUT OFF VALVE G 14•v <br /> p t„� ®1- ® - <br /> (Check all than apply) 91.SPILL CONTAINMENT Ol-C7 ❑2.BALL FLOAT_ ❑4.EXEMPT <br /> 6 2.DROP TUBE <br /> N 3-STRIKER PLATE WAt + <br /> IV.TANK LEAK DETECTION <br /> (A description of the monitoring program shall be submitted to the local agency-) 454. <br /> as3. IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLE WALL TANK (Check one item only) <br /> ((deck all that apply) ❑5_MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> [13-CONTINUOUS ATG <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 7 457 <br /> a55. TANK FILLED WITH INERT MATERIAL. <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING ❑Yes ❑ No <br /> gallons <br />