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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of _ ❑ 5.CHANGE OF INFORMATION) ❑ 6.TEMPORARY SITE CLOSURE TYPE OF ACTION [31.NEW SITE PERMIT 134.AMENDED PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Check one item only) ❑ 8.TANK REMOVED 430 ❑3.RENEWAL PERMIT (SP�IY reason•/orlocal use only) (Speciry change-to, use only) -R= 1 BUSINESS NAME(Same a FACILITY NAME or DBA-Doing Business As) FACILITY LOCATION WITHIN SITE(Opffonaq 431 . 1.TANK DESCRIPTION TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No . If'Yes,complete one peg or chcompartment. TANK ID# t 79J_ 3f H '/3�' �' � � �� NUMBER OF COMPARTMENTS D 7E INSTALL (YEARA.10) TANK CAPACITY IN GALLONS a1 2 0 00 U 2- /2 ot�e coo ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS TANK USE 432 PETROLEUM Y.TYPEY"�^ LEADED ❑ 5.JET FUEL . MOTOR VEHICLE FUEL REGULAR UNLEADED ❑ 6.AVIATION FUEL (1I marked,complete Petroleum Type) 1b. �3.PREMIUM UNLEADED DIESEL ❑99.OTHER ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4.GASOHOL CAS#(!mm Hazardous Materials Inventory page ❑ 3. CHEMICAL PRODUCT COMMON NAME(rrom Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) - - III.TANK CONSTRUCTION ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM TYPE OF TANK Y�2 SINGLE WALL EXTERIOR MEMBRANE LINER - ❑95. UNKNOWN (Check one item only) .DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑99. OTHER i'"�❑L95. UNKNOWN TANK MATERIAL-primary tank ❑ J. BARE STEEL 3. FIBERGLASS/PLASTIC ❑ S. CONCRETE M 9g OTHER (Check one item only) ❑ 2.STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1• BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL x•99.OTHE95. R ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 4� (Check one item only) ❑ 2.STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑1o. COATED STEEL ❑ S. CONCRETE DATE INSTAL ED ❑ 3. EPDXY LINING - ❑ 5. GLASS LINING ❑95. UNKNOV43� Q TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 6. UNLINED ❑99.OTHER_ (For se only) OR COATING ❑ 2.ALKYD LINING ❑ 4.PHENOLIC LINING - DATE INS ALLED (Check one item only) 4 OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC O 99 OTHER (For to al use only) PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT Y� (Check one_item only) - ❑ 2. SACRIFICIAL ANOD YF1�R INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED SPILL AND OVERFILL �_ ❑ 1.ALARM 3. FILL TUBE SHUT OFF VALVE (Check all that appM D 1. SPILLCONTAINMENT C L u7Q _ ❑ 4. EXEMPT ❑ ❑ 2. BALL FLOAT 2. DROP TUBE ❑ 3 STRIKER PLATE ,... , € NTNiFLEAK'DEIECTtOtS:." .- -w• °-" IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only). IF SINGLE WALL TANK(Check all that ap N).' ❑ 5 MANUAL TANK GAUGING(MTG) El1. VISUAL(SINGLE WALL IN VAULT ONLY) . ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. VADOSE ZONE X2. CONTINUOUS INTERSTITIAL MONITORING El2. AUTOMATIC TANK GAUGING(ATG) ❑ 7 GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER INFORMAT CE V.TANK CLOSURE ION!PERMANENT CLOSURE 143�C TANK FILLED WITH INERT MATERIAL? ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons ❑Yes ❑No Formerly SMCB Form CUPAFORM(4/99)