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Vyj[L o\ UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per lank) Page of� 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. TYPE OF ACTION ❑ 1.NEW PERMIT [:3 4, 7 PERMANENTLY CLOSED ON SITE (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 8.TANK REMOVED (Specify reason) (Specify reason) 1. BUSINESS NAME(Same ^a FACILITY NAW or DBA-Doing Duinms As) 3. FAFCI�(LITY[D: s - E LS / 431. LOCATION WITHIN SITE(optional) (� c�SE�^• �`S.r t_.� `Fa C 1 L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and 33an OmrART ALIZED Te local K ❑Yes ❑ No 434. TANK ID# 434. TANK MANUFACTURER If"Yes,"complete one page for each compartment 17G r olq ,/o& (�W�� ' C"' n :=436. NUMBER OFCOMPARTMENTS 437. DATE INSTALLED 43s. TANK CAPACITY IN GALLONS (YEAR/MO) \K) (�V (J 438. ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS ciao. F 439. PETROLEUM TYPE EHICLE FUEL ❑la REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL Petroleum Type) ®lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS 4. GASOHOL ❑99.OTHER: L PETROLEUM ❑lc. MIDGRADE UNLEADID ❑ 4423. CHEIvAL PRODUCT COMMON NAME from Hauedous Materials hwemory Page) 44I. CAS#(from Hazardous Materials inventory paw) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN G S O L,' n (- HL TANK CONSTRUCTION ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM tai. TYPE OF TANK MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 62. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. t7THER 95.UNKNOWN 444, TANK MATERIAL-P=afY t�k 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP COMPATIBLE ❑99.OTIR: (Check one item only) REINFORCED PLASTIC W/100%METHANOL 5.UNKNOWN 445. D8 I;ljj� 05 TANK MATERIAL-secondary tool ❑2. S AINLESS SSTEEL❑4. ST_ELIna Eil,GCLAD W/FIBERGLASS ❑9.FRP NON ORROD/ABLE JACKET OL ❑99.OTHER (Check one item only) REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE 446. DATE INSTALLED 447. TANK INTERIOR LINING I.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING �si� O SOWN OR COATING ❑2 ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑ 449 DATE INSTALLED 449. Checkone item onl CATHODIC ❑3-FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN OTHER CORROSION ❑1.MANUFACTURID ❑4 IMPRESSED CURRENT ❑99.OTHER PROTECTION PROTECTION r(Chcck�5fltba-a e ❑2.SACRIFICIAL ANODE INSTALLED 450. T/Y,PE^ 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. SPILL OVERFILL t -py`+\A l ®1.ALARM C l_c 3®3.FILL TUItE SHUT OFF VALVE CI J j apply) 1@ 1.SPILL CONTAINMENT ❑2.BALL FLOAT_ ❑4.EXEMPT 2.DROP TUBE - 0 i -� ®3.STRIKER PLATE LLU ` IV TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) 414 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER rS NGLE W ALL TANK (Check one item only') k all that apply) ❑5_MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WAIL IN VAULT ONLY) VISUAL(EXPOSED PORTION ONLY) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING AUTOMATIC TANK GAUGING(ATG) ❑7.GROUNDWATER ❑3.MANUAL MONITORING CONTINUOUS ATG STATISTICAL OR RECONCII.IATION ❑8-T TESTING' (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WTM INERT MATERIAL? 457. ESTIMATED DATE LAST USED(YR/MO/DAY) gallons ❑Yes ❑ No