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UNIFIED PROGRAM CONSOLIDATED FORM e T4,NKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 C (Two pages per tank) Page _ of_ TYPE OF ACTION M L NEW PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY TANK CLOSURE 430. t LLJ ❑ 7. PERMANENTLY CLOSED ON S (Check on3. RENEWAL PERMIT ITE e tem only) (Specify reason) (Specify reason) ❑ 8. TANK REMOVED B SINE S NAME (Same as�CILITY NAME or DBA -Doing Buses As) 3. FACILITY ID: 1. 431. �, LAPIK IBLJi.KiY-1 iVlr (A scaled plot' Ian with the location of the UST including buildings and landmarks shall be submitted to the local enc .} TANK ID # 432 TANK M ACTURER =i, ( :- '" _ a33. COMPARTMENTAL IZED TANK Yes No 434. . ('A D5 f G'/ GO n _ - _ If,,Yes;' complete one page for each compartment. J DATEINSTALLEDJ 435• TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437. (YEAR/MO) iZ-3 -off.. r a ADDITIONAL DESCRIPTION (For local use only) 438. 11. TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. P 1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If checked, complete Petroleum Type) Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION GAS ❑ 2. NON -FUEL PETROLEUM lc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER: 442. ❑ 3. CHEMICAL PRODUCT 441 . COMMON NAME (from Hazardous Materials Inventory page) CAS# (from Hazardous Materials Inventory page ) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 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 ❑ 95. UNKNOWN 2. DOUBLE WALL [14, SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL - primary tank 1. BARE STEEL 3. FIBERGLASS / PLASTIC 5. CONCRETE 95. UNKNOWN ar 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 0 1. BARE STEEL ❑ 3. FIBERGLASS/ PLASTIC 0 8. FRP COMPTIBLE W/ 100% METHANOL 95. UNKNOWN 445. (Check one item only) ❑ 2. STAINLESS STEEL �E4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODABLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL [15. CONCRETE OR LINING TNGLINU 5gf6. GLAS LINING95. WN 446. DATE INSTALLED 447. OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC UNLINED ❑ 99. OTHER Check one item on! OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC MD. 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. E 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED OFF VALVE 452. (Check all that apply) 1. SPILL CONTAINMENT X M,1. ALARM -3. FILL TUBE SHUT 4. EXEMPT 2. DROP TUBE 2. BALL FLOAT _ NB 3. STRIKER PLATE IV. TANK LEAK DETECTION shall ntm o he local agency-)e 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. IF SINGLE WALL TANK (Check one item only) (Check all that apply) ❑ 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 Tq 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 I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/455. DAY) 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