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FROM, (THU)JUN 10 2004 12 /ST. 12 ;27/No. 680795 51�P�P 2 <br /> �1 11 <br /> k)0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM /�y/ONL <br /> I 1 TANKS @#' <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two es rank) <br /> Pie Of <br /> E: <br /> TYPE OF ACTION 1 NEW SITE PERMIT 4 AMENDED PERMIT 5 CHANGE OF INFORMATION 0 6 TEJAPORARY SITE CLOSURE <br /> Iowa me dun awy) ❑ 7 PERMANENTLY CLOS80 ON SITE 111� <br /> ❑ 3 RENP.WAL PERMIT (Spmfy,*""_f6rjog_.cjy) (SPec*_3on-f6ri*w.. .oy) ❑ STANK REMOVED 430 <br /> USINFSSNAME(S—.FAcnmNAW wOIJA-DaisBusimA,) 1 3 1 FACILITYux 1 <br /> LJ <br /> ' t iZf� <br /> LOCATION WTTIIN SITE(opw w) 431 <br /> S k_a <br /> 1,TANK DESCRIPTION (A scaled plot plan With the location of the UST System including Iglildings and landmarks shell be submitted W the local ency.) <br /> TANK ID# 422 TANK MANUFA 171 COMPARTMENTALIZED TANK Yes No 4t4 <br /> 1 TQ' Seo 7 it-Yml.mnoete p.se <br /> DATE INSTALL D(YEAR/MO) 4)5 TANK CAPACITY IN GALLONS 4s5 NUMBER OF COMPARTMENTS 477 <br /> 1004 ro o_. <br /> ADDITIONAL DESCRIPTION(F«lea ee ootr) 436 <br /> II.TANK CONTENTS <br /> TANK USE 479 pa/ <br /> LEUM I YPE 440 <br /> i. MOTOR VEHICLE FUEL Is, REGULAR UNLEADED ❑2. LEADED C35, JFT FUEL <br /> (lfmmAid Mnytle ePevolepm Type) ❑Ib, PREMIUM UNLEADED ❑3, DIESEL 0 6, AVIATION FUEL <br /> ❑2. NON-FUEL.PETROLEUM ❑Ic. MIDORADE UNLEADED O 4.OA50HOL ❑99.OTHER <br /> 411 CAS){(clam tlwrdous Maai.lc Invemty Pte) <br /> Q 7, CHEMICAL PRODUCT COMMON NA MF.(fbmoH�dpm Mrxidy/nI'm�snaryptee) <br /> ❑4. HAZARDOUS WASTE <br /> (lnd.ielLbadVil) <br /> ❑95.UNKNOWN <br /> ILL TANK CONSTRUCTION <br /> TYPE OF TANK 0 I, SINGLE WALL LJ 3, SINGLE WALL WITH S, SIN(ILE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Chxk omo 0op,only) / EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> 2. DOUBLE WALL O SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-pnm4tyunk U 1. BARE STEEL 3. FIBERGLAS5/PLASTIC 5. CONCRETE ID 95. UNKNOWN 4" <br /> (('byck eac.rc only) Q2. STAINLESS J'I'EN,I, Q4. STEEL CLAD W/PIBERGLASS 09- FRPCOMI''ntm.F,W/f00%MJ3MLINOL E3 99.OTHER <br /> INNOt(CED PLASTIC(FRP) <br /> TANK MATERIAL-.ecoed4ry I-nk L BARE STECL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN <br /> (Ck6 one item only) Q 2. STAINLESS STEEL Q 4. STEEL CLAD WTI BEROLASS [IS. PRP COMPTIBLE W/IW%METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) El 10.COATED STEEL <br /> 0 5.CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED U 3.EPDXY LINING C1 GLASS LINING U 95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING 0 4 PHENOLIC LINING 6 UNLINED 0 99 OTHER <br /> (cheek one item anhl (Poe Loa we only) <br /> "I qATE INSTALLED 449 <br /> OTHER CORKOSION O 1 MANUFACTURP.D CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC 5f95 UNKNOWN <br /> PROTEC'RUN IF APPLICABLE PROTECTION ❑4 IMPRLSSED CURRENT ❑99 OTHER <br /> (CReck me item only) ❑2 SACRIFICIAL ANODE (P.kKA 1p°�) <br /> SPILL.AND OVERFILL YEAR 1NSTALLF,D 450 TYPE(lord a-my) 451 OVfl�IAALLFLOAT <br /> ER�ILL PROTECTION EQUIPMENT:YEAR!)`'STALLED 452 <br /> (Check dl thr.pply) SPILL CONTAINMENT '(�] I RM ©3 FILL TUOU SI IUT OFF VALVE <br /> fROP TUBE O 4 WCEMFT <br /> 3 STRIKEK PLATE <br /> IV.TANK LEAK DETECTION(A dmcriptim or&*ppniwrinapmF m sb&b-eeb.n.atd n the Ioc.I.sacra <br /> IF SINGLE WALL TANK(0—k d1 thr W00 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> F2CW'MNUOUS <br /> I.em o.N) <br /> Q 1 VISUAL(EXPOSED PORTION ONLY) 0 5 MANUAL TANK GAUGTNO(MTG) AL(SINGLE WALL IN VAULT ONLY) <br /> Q 2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE INTERSTITIAL MONITORING <br /> ❑1 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> Q 4 STATISTICAL INVENTORY RECONCILIATION O 8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ©99 OTFiF'R <br /> IV,TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR(MO/DA Y) 453 ESTIMATED Ql1ANT17Y Of SUBSTANCE REMAINING 456 TANK FILLED WITF TNPRT MATERIAL? 457 <br /> gallons ❑it" ❑ No <br /> UPCF(12/99 revised) 10 Formcdy SWRCB Form B <br />