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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 Dyt C. 01 TANKS (tiro pages per tank) Page _ of TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑ 3. RENEWAL PERMIT (Specify reason • for local use only) (Specihy change -for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) FACILITY 10 to t 71717111 o LOCATI N WITHIN SITE (0;dcna4 431 I. TANK DESCRIPTION TANK 10 a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No _ `l If -Yes', complete one page for eachcomparsr.ent. a oda i v- r, u DATE INSTALLED (YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCR PTION I;crlocal use only) II. TANK CONTENTS TANK USE 432 PETROLEUM TYPE 54 1. MOTOR VEHICLE FUEL ❑ to REGULAR UNLEADED ❑opII 2. LEADED ❑ S. JET FUEL (If marked, complete Petrcldw,m Type) ❑ 1b. PREMIUM UNLEADED (a� 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ 1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) from Hazardous Matenats M Ina nto page) CAS ( ry p g ) ❑ 4. HAZARDOUS WASTE (Includes Used Od) 1195 UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item on/Y) IQ 2 DOUBLE WALL EXTERIOR MEMBRANE LINER C195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL - primary tach jja 1 BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W".". METHANOL ❑ 99 OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL • secondary tank ❑ 1 BARE STEEL ❑ 3 FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W1100% METHANOL ❑ 95. U14KNO`NN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON•CORROOIBLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) M110. COATED STEEL ❑ 5 CONCRETE TANK INTERIOR LININGGATE ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING INSTALLED ❑ 5. GLASS LINING ❑ 95. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING [S116. UNLINED ❑ 99. OTHER (For local use cnhp (Check one item on DATE INSTALLED OTHER CORROSION NUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 434 PROTECTION IF APPLICABLE ❑ 4. IMPRESSED CURRENT ��PROTECTION ❑ 99. OTHER (For local(Check one item only) CRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE (For local use only) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED (Check all that apply) 19 1 SPILL CONTAINMENT 10 1. ALARM Q-0 tq 3. FILL TUBE SHUT OFF VALVE ` �1 EA 2. DROP TUBE _aJ❑ 2. BALI FLOAT ❑ 4. EXEMPT LO. 3. STRIKER PLATE N. TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): IF SINGLE WALL TANK FCAack ell that ap ): 1. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ I. VISUAL (SINGLE WALL IN VAULT ONLY) p❑ yk 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE Iq 2. CONTINUOUS INTERSTITIAL MONITORING 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) • ❑ B. TANK TESTING BIENNIAL TANK TESTING ❑ 99. OTHER V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WATH INERT MATERLAL7 TESTIMATED gallons ❑ Yes ❑ No CUPAFORM (4199) Formerly SVVRCB Form B