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ANI <br /> 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) <br /> Page�of x <br /> 0 ED PERMIT ❑5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430 <br /> TYPE OF ACTION ❑ I-NEW PERMIT ❑ AMEND ❑ PERMANENTLY CLOSED ON SITE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> (Speaty teaton) (5}Kafy rea_so°) ❑ 8.TANK REMOVED <br /> t <br /> s. CFACIIIJT�Y�IDBUSINESS NAME(SameasFACBITY NAME orDBA-Doing Business As) 431 <br /> LOCATION WITHIN SITE(Optional) <br /> E L TANK DESCRIPTION <br /> (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency) <br /> ANY,ID#�] as2. TANK MANUFACTURER <br /> 4ss. COMI'ARTMENTALIZED TANK ❑Yes ❑ No 434 <br /> 7 ��{ O if"Yes"complete one Page for eacL compmam®,. <br /> �� to�f0� <br /> ash. NUMBER OF COMPARTMENTS 437 <br /> DATE INSTALLED 435 TANK CAPACITY IN GALLONS <br /> (YEAR/MO) O Q D <br /> 43K <br /> V1r <br /> ADDITIONAL DESCRIPTION(For low use ooly) <br /> IL TANK CONTENTS <br /> 440 <br /> TANK USE 439. PETROLEUM TYPE <br /> g 1.MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED [12. LEADED [15. JET FUEL <br /> (If chatted,complete Petroleum Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION GAS -- <br /> 99. <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic.MIDGRADE UNLEADED ❑4. GASOHOL [3CAS#(from FlaardousMateri�inventory page) 442 <br /> ❑ 3. CHEMICALPRODUCT COMMON NAME Hazardous(6om Bardous Martial'tn`entmy Page) <br /> ❑ 4. HAZARDOUS WASTE <br /> (Indudes Used Oil) <br /> ❑ 95.UNKNOWN S <br /> UL TANK CONSTRUCTION 443 <br /> TYPE OF TANK F31. SINGLE WALL ❑3•D�IIBRANE � E3CIIiRIOR ❑95 SUNKNOWN INGLE WALL WTTII IN PERNAL BLADDER SYSTEM <br /> (Check one item only) 4. SINGLE WALL IN A VAULT ❑99. OTHER 444 <br /> ®2.DOUBLE WALL ❑ 5. CONCRETE 95.UNKNOWN <br /> TANK MATERIAL-primary <br /> tante 1. BARE STEEL 3.FIBERGLASS/PLASTIC <br /> ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP COMPATIBLE 99.OT <br /> (Check one item only) REINFORCED PLASTIC WCOM METLLANOL <br /> 8. <br /> TANK MATERIAL-secondary tank ❑2_B AE ESS STEEL.[14. SITES CLAD W/FIBERGLASS Br ❑9.FRP NO -CN ORROD/ABLE JACKET THANI OL UNKNOWN❑99.OTHER <br /> 445 <br /> (Check one item on)y) REINFORCED PLASTIC(FRP) ❑10_ COATED STEEL <br /> ❑5. CONCRETE 446. DATE INSTALLED 447. <br /> TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS I INWG ❑ .UNC OWN <br /> OR COATING [12-ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED <br /> Check one item onl CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC [15115.UNKNOWN <br /> 448. DATE INSTALLED 449. <br /> OTHER CORROSION ❑1.MA--------RID ❑4.IMPRESSED CURRENT ❑99.OTHER <br /> PROTECTION PROTECTION <br /> A likable ❑2.SACRIFICIAL ANODE3.FILL TIME SHUT OFF VALVE C <br /> SPILL AND OVERFILL INVERFILL PROTECTION EQUIPMENT= YEAR INSTALLED <br /> YEAR STALLED aso. TYPE 451. O <br /> a <br /> 1.ALARM Off_ ■ <br /> (Check A that apply) ®1-SPILL CONTAINMENT Q) ❑2.BALL FLOAT_❑4.EXEMPT <br /> 2.DROP TUBE <br /> p -D <br /> IN 3.STRIKER PLATE ✓ <br /> IV.TANK LEAK DETECTION <br /> (A descri on ofthe monitoring program shall be submitted to the local agency-) 454 <br /> ass. IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> IF SINGLE WALL TANK (Check one item only) <br /> (Check all that apply) ❑5.MANUAL TANK GAUGING(MIG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.VANOSE ZONE E 2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2. AUTOMATIC TANK GAUGING(ATG) ❑7.GROUNDWATER ❑3.MANUAL MONITORING <br /> ❑3.CONTINUOUS ATG <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8-TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE 457 <br /> 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 456. TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) - gallons ❑Yes 0 No <br />