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i �M�le ( - UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (fW0 pages per tank) Paye _ of TYPE OF ACTION 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 15. TEMPORARY SITE CLOSURE (Check one dem only) C1 1.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Sperily reason-for local use onty) (Spaofy change•for local we oNy) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or OBA.Doing Buvnesa As) FACILITY 10 e 1 UNITED GAS LOCATION WITHIN SITE(Option"" 431 ^ `1 b wo (, 1.TANK DESCRIPTION TANK 10 a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes JQCNo TRUSCO If-Yoe.complete one page for eacn comvsrtnenl. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 10-99 20, 000 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS TANK USE 432 �4�II PETROLEUM TYPE yy �_��` MQTOR VEHICLE FUEL 1a. REGULAR UNLEADED ALAI [. Le�vcv ❑ 5. JET FUEL (if mar�sa,complete Fwm;..m Type) ❑to. PREMIUM UNLEADED ❑ 1. DIESEL ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM Cl Ic MIOGRAOE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ J CHEMICAL PRODUCT ❑ 4 HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Matenals Inventory page) CAS 0(Imm Hazardous Marenals Inventory page) Used 010 C1 5oIJNY III.TANK CONSTRUCTION TYPE OF TANK ❑ 1 SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WATH INTERNAL BLADDER SYSTEM (Chock one der^only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER Cl 95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1, BARE STEEL ❑ 1. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Chock one dem only) ❑ 2. STAINLESS STEEL A. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE VW100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE`M700%METHANOL ❑95. UNKNOWN (Check one dem only) ❑ 2. STAINLESS STEELJF 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON.CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 1. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING C14. PHENOLIC LINING C18. UNLINED C199. OTHER (Check one demo ) (Fpr focal use Dory) OTHER CORROSION ❑ i MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 43.1 GATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑99. OTHER (Check one dem only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check ak that apply) 1. SPILL CONTAINMENT 344 1. ALARM 7f 3. FILL TUBE SHUT OFF VALVE ® 2. DROP TUBE 2. BALL FLOAT ❑ 4 EXEMPT Cid 3 STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK Check as that ap ): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one kem only) 0 n )❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE 51 2, CONTINUOUS INTERSTITIAL MONITORING ❑ 1. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 1. MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes Cl No a ) S S l/251a� C P/a e)oo - r 0 S curAFOR'm(4:)9) Formerly S1,VRCB Form F