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U97FIED PROGRAM CONSOLIDATED FOR f7 TANKS o UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages pe ank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430 (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: t GlR1V-rl..t'.S cac(5 tt ' LOCATION WITHIN SITE(Optional) 4;1 �✓. 4/ �Y I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shalt be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433• COMPARTMENTALIZED TANK ❑Yes ® No 434. 01 Xerxes If"Yes"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437 12-20-03 30,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 U.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440 ® 1. MOTOR VEHICLE FUEL ®I a. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If checked,complete Petroleum Type) ❑ 1 b. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442_ ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑I. SINGLE WALL [13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ I. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑ 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ®8. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447 OR COATING ❑2.ALKYD LINING [14.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [:13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448, DATE INSTALLED 449, PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER If A licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 2003 ❑1.ALARM ®3.FILL TUBE SHUT OFF VALVE 2003 ®2.DROP TUBE 2003 ❑2.BALL FLOAT ❑4.EXEMPT ®3.STRIKER PLATE 2003 IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453_ IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) [11. 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 MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00