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• UNIFIED PROGRAM CONSOLIDATED FORM • TANKS UNDERGROUND STORAGE TS-TANK PAGE 1 (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 item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specifyrcason) (specifyrcason) ❑ 8.TANK REMOVED BUSINESS NAME(Saw wFACILITY NAME orDBA-DoimgBusincssAs) 3. FACILITY ID: 1 PCL e' ' M4nI - + `i- Ga Ir 0 ® d �4 J 1 ,9-1 LOCATION WIMINN SITE(Optional) (t 46 ®f b 0 S-q C) 431. 5 I 1 1" e-i C. e - I I.TANK DESCRIPTION A scaled plot plan with the location of the UST system including btlildin s and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK [-]Yes No 434. If'Ycs,-complete one page for each congwt-t. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 9, 000 ADDITIONAL DESCRIPTION(For local use only) 438. H.TANK CONTENTS ,,,,TArNK USE 439- PETROLEUM TYPE 440. 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5.JET FUEL Ifchcckcd,completePcnokum Type) PCI b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Mate ish,inventory page) �1' CAS#(from Ha78rdous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL ❑3. 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 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 03. 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 ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING [16.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER (IfA licable) Ej 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 45o. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all that apply) 1.SPILL CONTAINMENT u 2.BALL FLOAT_ LJ 4.EXEMPT �T OFF VALVE .DROP TUBE , O 3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring m 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) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE 10-2.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 hwfwre-b(1/99)-1/4 http://www.unidoesorg Rev.02/16/00