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0 a UNIFIED PR GRAM CONSOLIDATED FORM TANKS UNDERGROUND TORAGE TANKS -TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT 11f 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT 0W W EYE e4 PAC%rE ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ S.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: I HiQ O r (, IPA [ -- LOCATION WITHIN SITE(Optional) 431. Lt ST L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.),, TANK ID# 432. TANK MANUFACTURER UFACTURER 433. COMPARTMENTALIZED TANK ❑Yes Rg No 434. If"Yes,"complete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS a37. (YEAR/MO) / 16-1 ' ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. 06 1. MOTOR VEHICLE FUEL Nla. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. 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) ut 1 1! ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER [195. UNKNOWN R2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ®3. 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 113. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL [195.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL[14. 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 ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC [:195.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) 211.SPILL CONTAINMENT ® 19 1.ALARM ❑3.FILL TUBE SHUT OFF VALVE 19 2.DROP TUBE 2.60 [12.BALL FLOAT ❑4.EXEMPT 3.STRIKER PLATE 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) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE Qff 2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION [:18.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 hnp://www.unidocs.org Rev.02/16/00