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UNIFIED PROGRAM CONSOLIDATED FORM 1 TANKS Ir UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page - of - TYPE OF ACTION® 1. NEW PERMIT [34. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. a� (Check one item only) LLJ 3. RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8. TANK REMOVED BIUSINE5S NAME (same ajFfCII1TY NAME or DBA - Doing Business As) 3. FACILITY ID: 1 G L CATION WITHIN SITE (Optional) 1 431. TANK ID # 432• TANK M UFACTURER < C _r� DATE INSTALLED 435• TANK CAPACITY IN GALLONS (YEAR/MO) Z -3 -0'c 1 c) ADDITIONAL DESCRIPTION (For local use only) TANK USE 439. PETROLEUM TYPE IA 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED (If checked, complete Petroleum Type)lb. PREMIUM UNLEADED ❑ 3. DIESEL [12. NON -FUEL PETROLEUM [�] lc. MIDGRADE UNLEADED [14. GASOHOL ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) tank 1. BARE STEEL 3. FII3ERGLASS / PLASTIC ❑ 95. UNKNOWN 444. COMPARTMENTALIZED TANK ❑ Yes If"Yes," complete one page for each compartment. NUMBER OF COMPARTMENTS [15. JET FUEL ❑ 6. AVIATION GAS ❑ 99. OTHER: 4 L CAS# (from Hazardous Materials Inventory page ) 0 434. 437. 438. 440. TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR [15. 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. FII3ERGLASS / PLASTIC 5. CONCRETE 95. UNKNOWN 444. (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE ❑ 99. OTHER: REINFORCED PLASTICFRP W/100% METHANOL TANK MATERIAL - secondary tank 1. BARE STEEL 3. FIBERGLASS / PLASTICU 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 196. 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 If Applicable) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YE STALLED 450. ��ppE. 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1. SPILL CONTAINMENT 2. DROP TUBE�� OP0 I.ALARM _ tX3. FILL TUBE SHUT OFF VALVE 2. BALL FLOAT _ 4. EXEMPT IF SINGLE WALL TANK 453• IF DOUBLE WALL TANK OR TANK WITH B (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 12. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ❑ 8. TANK TESTING (SIR) + BIENNIAL TANK TESTING ❑ 99. OTHER ESTIMATED DATE LAST USED (YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons TANK FILLED WITH INERT MATERIAL? []Yes ❑ No UPCF hwfwrc-b (1/99) -1/4 http://www.unidocs.org Rev. 02/16/00