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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TAN_ K PAGE 1 <br /> TYPE OF ACTION (3 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT W 5 CHANGE OF(INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (Ch t wr iim only) �F�i 1Jr ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (speedyrt.wn-(m Iocw ..dy) (sped%na.ov-Cor bea o..aaY) ❑ STANK REMOVED 439 <br /> BUSINESS NAME(s® umcmrry NAWBmc -ooimtt ; .A.) FACILIT'YID: I <br /> 3 <br /> LOCATION WITHIN SITE(opi.Q 431 <br /> L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shell be submitted to the local agency.) <br /> TANK ID N 413 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 4l4 <br /> -.fit cF,x6r S- I-Yo.w '.ae.p for Mcb mopmemt <br /> DATE INSTALLED OTAR/MO) 415 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4l7 <br /> ADDITIONAL DESCRIPTION(pada moot') <br /> SQA � � Q. e6i 2p" <br /> 11.TANK CONTENTS <br /> TANK USE 419 PETROLEUM TYPE 4w <br /> 1. MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (I mated mmpw PaMW=Trp) 01b. PRII.1UM UNLEADED J3(3. DIESEL 06. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> 03. CHEMICAL PRODUCT COMMON NAME (ft.H.rndmu mm w.(mammy pp) 441 CAS#(tram HsaMmu Maria.W,.Wy pp) 442 <br /> ❑4. HAZARDOUS WASTE <br /> (ImA"Ud Ott <br /> [195.UNKNOWN <br /> 111. TANK CONSTRUCTION <br /> TYPE OF TANK 0 1. SINGLE WALL 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 <br /> (Chwf.e.n®nay) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> $2. DOUBLE WALL ❑4. SIGME WALL IN VAULT ❑99. OTHER ' <br /> TANK MATERIAL-prm mk 0 1. BARE STEEL 3. FIBERGLASS/PIASTTC 5. CONCRETE 95. UNKNOWN 444 <br /> (Cexk...as.oay) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FW ERGIASS ❑S. FRP COMPITBLE W1100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-.o..d.y b.k 0 1. BARE STEEL W3. F®ERGLASS/PLASTIC 0 5. CONCRETE - 0 95. UNKNOWN 445 <br /> (Chwk on.ilem only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑s. FRP COMPTIBLE W/I00%METHANOL ❑99.Omm <br /> REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING 136 UNLINED ❑99 OTHER <br /> (CbrY aroi ay) (Par Ioul um ovy) <br /> 4N 444 <br /> OTHER CORRASION ❑]MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER <br /> (Cbe3 om nem ay) ❑2 SACRIFICIAL ANODE (Fo,)a 1e4 o^I1) <br /> SPILL AND O .YEAR INSTALLED 450 TYPE(Inca u..ay) 451 OVERFU L PROTECTION EQUIPMENT:YEAR INSTAI.I.ED 452 <br /> (Cbsk a1 tIw w*) M I SPIL CONTAINME N7 Zola <br /> ❑) ALARM W7FI1.L TUBE SHUT OFF VALVE, <br /> ®"2 DROP TUBE ❑2 BAIL FLOAT ❑4 EXEMPT <br /> a3 STRIKER PLATE i 9 <br /> N.TANK LEAK DETECTION(A&.v Foo orfs monammg poP.m AW I. b.60W mds loeWa) <br /> IF SINGLE WALL TANK(c3 an fm wry) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 434 <br /> (LLmt non mM a y) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MIG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑e TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING []99 OTHER <br /> N.TAI NK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOJDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 4S6 TANK FILLED WITH INERT MATERIAL? <br /> gallore ❑Yes ❑ NO <br />