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v ■'ts <br /> II, UNIFIED PROGRAM CONSOLIDATED FORM <br /> rr TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> R o pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION 0 1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Check ons rfem only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specty Mason-for local use o (Spat y charge-for local use o <br /> Hyl Nyl ❑ 8. TANK REMOVED 410 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Domg Business As) FACILITY 10 a 1 1 <br /> I <br /> UNITED (3AS Fn <br /> LOCATION WITHIN SITE(Optionao 431 <br /> I.TANK DESCRIPTION <br /> TANK 10 a TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes )E�kL.JINo <br /> TRUSCO If'Yes.oomplete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 10-99 20,000 <br /> ADDITIONAL DESCRIPTION(For loca(use,or.W <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ta. <br /> �.`..MQTOR VEHICLE FUEL y1�1a. REGULAR UNLEADED "-W T.'CFJCOED ❑ 5. JET FUEL <br /> (If maria.complete Petroleum Type) ❑1E. PREMIUM UNLEADED ❑ 1. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Mafenals Imentory page) CAS a(from Hazardous Materials Inventory page) <br /> Used OiO <br /> -5UNY <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one Rem onW Q 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-pnmary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one rfem only) ❑ 2. STAINLESS STEEL FLI 4. STEEL CUD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC 1FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WrtOo%METHANOL ❑95. UNKNOWN <br /> (Check one Rem only) ❑ 2. STAINLESS STEEL 4. STEEL CLAD WfFIBERGLASS ❑ 9. FRP NOWCORROOIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS UNII4G ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> Cl 2. AL.KYO LINING ❑ 4. PHENOLIC LINING ❑ B. UNLINED ❑99. OTHER <br /> (Check one Rem ow (For local use on <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one Rem only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use onto OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that appl)) C1 1 SPILL CONTAINMENT 1. ALARM :P 3. FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE 2. BALL FLOAT ❑ 4 EXEMPT <br /> 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check as that ap IF DOUBLE WALL TANK OR TANK WITH BLADDER(Chock one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE R 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4 STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> genome <br /> ❑Yes ❑No <br /> CUPAFORM(4199) Formerly SVVRCI3 ForrTI E <br />