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J - a UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 T; (two ages per' al J Pw-L d TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ary 5 CHANGF.OF INFORMATION ❑ 6 TEMPORARY SIn CLOSURE (chmk oro nem only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Spe dl .o. fo I.W.auy) (Spay rawo-tor oral u.e WY) ❑ a TANK REMOVED 430 BUS SS NAIv1E(Sm.0 PACI.DY NAIdE orI3BA-pup awiora A.) FACILITYID: z OCATION WMINSTYE(opm .0 -.. 43I L TANK DESCRIPTION (A scaled plot plan with the location dFthe UST system including buildings and landmeda shall be submitted to the local agency.) TANK IDN 432 TANKMANUFACTURER 053 COMPARTMENTALIZED TANK -Yes No 4N IRs.",mmplaa am p.8e far arh mraP.ronam DATE INSTALLED(YEAR/MO) 433 TANK CAPACITY IN GALLONS 476 NUMBER OF COMPARTMENTS 437 /D.DOD ADDITIONAL DESCRIPTION(Pabst.(e my) atl 11.TANK CONTENTS TANK USE 419 PETROLEUM TYPE 4M 12 L MOTOR VEHICLE FUEL ®"IL REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (ifmk.4 C0.om P1ao1.T' ) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ia. FIDCRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (fi.H.Td.I&,-w-1 ..aynye) N( CAS#(Imm H.wdma mm w,loveaay pegs) 442 ❑4. HAZARDOUS WASTE (b Ww Ud Oil) ❑95.UNKNOWN - Dl. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL - 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (C1 t-nem aey) EXTERIOR MEMBRANE L94ER 095. UNKNOWN 22. DOUBLE WALL ❑4. SIGNIE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primey u.k 0 1. BARE STEEL 193. FIBERGLASS/PLASTIC 5. CONCRETE El 95. UNKNOWN 4.4 (Chert am n.m only) ❑2. STAINLESS STEEL 2t4. STEEL CHAD W/FBFRGLASS [IS. FRP COMPTBLE W/100%AlETHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-.ecarAa wk 1. BARE STEEL 3. FIBERGLASS/PLASTIC ETT CONCRETE 95. ui 0 WN 443 (Cbmk m item ooy) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPITBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LD41NG OLRUBBERLINED 3.EPDXY LINING 5.GLASS LINING 095.UNKNOWN 446 DATE INSTALLED Ny OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LANG ff 6 UNLINED ❑99 OTHER (Chert aoe km ady) (Far lor.l uw a.ty) OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 4N DATE INSTALLED 4a9 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Chert see has my) ❑2 SACRIFICIAL ANODE (Pae k.9 uw say) SPILL AND O .YEAR INSTAL 1 FD Oso TYPE n w..dy) 431 OVERFILL PROTECTION EQUIPMENMYEAR INSTALLED 432 (Cbak JI".pply) ®1 SPIT.CONTAINMENT "... _ ❑1 ALARM ff 3 FILL TUBE SHUT OFF VALVE - ®2 DROP TUBE '`' ❑2 BALL FLOAT ❑4 EXEMPT 193 STRIKER PLATE W.TANK LEAK DETECTION(A dmwigba dar rmohorip propam.6J1 a arbmarc4 nm.bul yeecy.) IF SINGLE WALL TANK(chat dl thm w*) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 434 (CLert a hem ody) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONrrORING ❑4 STATISTICAL INVENTORY RECONCI.ATION ❑S TANK TESTING (SIR) BIENNIAL.TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 435 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 436 TANK FILLED WITH INERT MATERIAL? 457 _ gallons ❑Ya ❑ No wry-4 iJ 5