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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -- TANK PAGE I (Two pages per tank) Page / of TYPE OF ACTION 1,NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one itcmonly) O 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Spec;fy reason) (Specify reawn) 8.TANK REMOVED BUSINESS NAME(SIM IS FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: I. f12 e LOCATION WITHIN SIT£(optional) 431 I TANK AESGRIFTZ`QN ;scal'ed plot plaq With the,.locat:ion of-the UST s s(efn,in�lgdts? uildtn and:landmarks shall 4e�u6mittcd:jQ;t}�e TANK ID N 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Yes o 434. UV)/` If"Yet,"complete one page for each compvtmsnt. DATE INSTALLED / 435. TANK CAPACITY IN GALLLNUMB_ ER 436• NUMBER OF COMPP7ARTMENTS (YEARJMO) �y ,1�\ 437. ADDITIONAL DESCRIPTION(Fpr local use only) �y �7 �f f J" 1 (� C,r✓.�►J�<�,4 r � %�.N/C 438. A TAfiI1C COTI TANKUSE 439. PETROLEUM TYPE 444 ❑ 1. MOTOR VEHICLE FUEL ❑Ie, REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL f � (If checked,wmpletePetroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADEUNLEADED 04. GASOHOL ❑99.OTHER: .__. ��j� �� QIG ❑ 3. CHEMICAL PRODUCT COMMONNAME (from Hazardous Materials Inventory page) 441• CAS4(from Hazxdous Materials Inventory pale) 442. ❑ 4. H04) US WASTE (Includes UsedsedOif) ❑ 95,UNKNOWN TYPE OF TANK SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. 5 ING E WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195, UNKNOWN ©i�C� c ;,1,4:E_7 ❑2. DOUBLE WALL 4, SINGLE WALL IN A VAULT 99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 5. CONCRETE cheek one item 2. STAINLESS STEEL ❑95.UNKNOWN 444- { y) ❑ ❑4. STEEL CLAD W/F[BERGLASS ❑ . FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank C1 1. BARE STEEL 3. FIBERGLASS/PLASTIC 8, FRP COMPTIBLE W/100%METHANOL Cf9J.UNKNOWN W. (Check one item only) ❑2. STAINLESS STEEL ❑4, STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET FRP [3 99.OTHER REINFORCED PLASTIC T (FRP) ❑l0. COATED STEEL 5. CONCRETE TANK INTERIOR LINING Ej 1.RUBBER LINED LJ 3.EPDXY LINING 5,GLASS LINING .UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING [:14.PHENOLIC LINING ^.UNLINED [:).99.OTHER Chock one item only) OTHERCORROS ON ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC 5.UNKNOWN 443, DATE INSTALLED 449. PROTECTION PROTECTION ❑4.3MPRESSED CURRENT ❑99.OTHER (IfApplilabK 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTA;�/ So. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Chuk all that apply) ❑1.SPILL CONTAINMENT 17-11.ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ` ❑2.BALL FLOAT ❑4.EXEMPT 3.STRIKER PLATE : IV.VAN-k r E Ak"DtT (A:descriptign.ctf,(he,mon storing,-program shall be sphinl(ted ao tHg local ageney:. . IF SINGLE WALL TANK 453• IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item ordy) ❑1. VISUAL(EXPOSED PORTION ONLY) �4.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 MONITORING [-14.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99, OTHER V. TAI�3K 4X O$UI? XIZIFOAQI?I!~Tse+RA] I>F fYJQSUR �P+ILrLCE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 45z gallons ❑Yes ❑ No UPCF hwfwrc-h(1199)-114 http:llwww.unidocs.org Rev.02/16/00 11