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UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 �$ 1I�(,W,Pages per tank) <br /> Page _ of U <br /> CHANGE OF INFORMATION) ❑ 8.TEMPORARY SITE CLOSURE <br /> S.C1 \ OI Vel <br /> TYPEOFACTION �1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ T. PERMANENTLYCLOSEOON SITE <br /> (Check..HemonM ��-- S cAange-rorbcal use oMy)naao <br /> ❑ ❑ e. TANK REMOVED 430 `Ix,VaJJ� <br /> 1RENEWAL PERMIT (SPer1A' n-rorrouluae oMy) ( Peaty I <br /> BUSINESS NAME(Same as FACILITY NAME or Duairo <br /> BA-Doug Bes Aa) <br /> FACILITY ID t: ' <br /> LOCATIONwmtsi SITE(O1rMO 431 <br /> 340 A/1 ,yHiGHR> '2 D.e• Tei¢e cfl <br /> I.TANK DESCRIPTION ❑ Ne <br /> TANK MANUFACTURER LOMPARTMEINTry V,co <br /> TANK <br /> TANK IOM mplete one page,a aNacompamnenL <br /> I. I " TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEAR/MO) CJD/oG'xG7 <br /> 2002 09 O` <br /> ADOITIONAL DESCRIPTION(Pa tical use.' <br /> IL TANK CONTENTS <br /> TANK USE - 433 qq PETROLEUM TYPE ❑ 5.JET FUEL <br /> )sw1a. ❑ 3.LEADED <br /> �1. MOTOR VEHICLE NEL REGULARUNLEADED ❑ 3. DIESEL ❑ 8.AVIATION FUEL <br /> (1/markeE,compNN P41misum Type) <br /> 01b. PREMIUM UNLEADED ❑g9, OTHER <br /> ❑ 2. NON-FUELPETROLEUM 01a MIDGRADE UNLEADED ❑ 4.GASOHOL <br /> ICALPRODUCT CASe(I/wn Hazardous Mefanala/nwnrorypage) <br /> ❑ 3. CHEM <br /> COMMON NAME(hom Hazardom Material.lnwnrorypepe) <br /> ❑ 4. HASARDOUS WASTE(Inot e- <br /> WIN!ch) <br /> III.TANK CONSTRUCTION <br /> ❑ 3 SINGLE WALL WITH ❑ 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> TYPE OF TANK ❑pp 1, SMGLEWALL IE(TERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Cheokaru Hem.w p 2. DOUBLE WALL ❑ 4 SINGLE WALL IN A VAULT 099. OTHER <br /> pp ❑95. UNKNOWN <br /> TANK MATERIAL-yrynary Unk ❑ 1. BARE STEEL Va.3. FIBERGLAS$/RUSTIC ❑ S. CONCRETE <br /> (ChecM one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CUD W/FIBERGLASS ❑ B. FRP COMPATIBLE WIIW%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-femndary Wk ❑ t SARE STEEL ❑ 3. FIBERGLASS I RUSTIC ❑ B. FRP COMPATIBLE W/103%METHANOL ❑N.UNKNOWN <br /> (Check.Hem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD WIFIBEPLASTIC <br /> ❑ 0 FRP NON.CCOATED <br /> RRODIBLE JACKET <br /> ❑89.OTHER <br /> REINFORCED RUSTIC(F0.P) ❑10 COATED STEEL <br /> ❑ S CONCRETE DATE INSTALLED <br /> TANK ❑ 1.RUBBER UNED ❑ 3. EPDXY LINING ❑ S. GLASS LINING ❑95. UNKNOWN493 <br /> OCOAPNG RCOATETtIOR LINING ❑ e. UNLINED 099.OTHER Forlacelu» <br /> OR <br /> ❑ 3. ALKYD LINING - ❑ 4. PHENOLIC LINING DATE INSTALLED <br /> (CAeck oru Item o <br /> rl 95.OTHER CORROSION ❑ 1, MANUFACNRED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑99. OTHER 434 (Farlocal...Nyl <br /> PROTECTION IF PPPLIGABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br /> (Cl oaainnnan ) ❑ 2. SACRIFICIALANODE. OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> YEAR INSTALLED TYPE(Fabcal use eNy) <br /> SPILL AND OVERFILL - <br /> ❑ L ALARM ❑ 3. FILLTUBE SHUT OFF VALVE <br /> (ChaokaItmat apply) ❑ 1. SPILLCONTAINMENi <br /> ❑ 2. BALL FLOAT_� ❑ 4. EXEMPT <br /> ❑ 2. DROPTUBE <br /> ❑ 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION. <br /> IF DOUBLE WALL TANK OR TANK WITH BUDDER(CrrecN aha item only): <br /> IFSINGLE WALL TANK(Check all mS. MANVALTANK GAUGING(ATG)al APPW ❑ 1. VISVAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ , <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 8 VADOSE ZONE ❑ 2. CONDNUOUS INTERSTITIAL MONITORING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 3. CONTINUOUSATG. 1 ❑ q, GROUNDWATE <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑8, OTHER <br /> TANKTESTING <br /> BIENNIAL TANK TESTING - <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE N <br /> ' 4]5 TANK FILLED VATM INERT MATERIALT <br /> ESTIMATED DATE UST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING - <br /> ga0om ❑Yea ❑No <br /> FoITnedY SWRCB Fomo <br /> CUPAFORM(4199) <br />