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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4. AMENDED PERMIT (Check one item only) ❑ 3. RENEWAL PERMIT (Specify mason - for local use only) X5. CHANGE OF INFORMATION) (Specify change - for local use only) TANKS (two pages per tank) Page _ of ❑ 6. TEMPORARY SITE CLOSURE ❑ 7. PERMANENTLY CLOSED ON SITE ❑ S. TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) -1 FACILITY ID # 1 / - a v / 1 / IVN/ /`J/ )431 KI Hll i � I V /1,�/i LOCATION WITHIN SITE (Op" /� I. TANK DESCRIPTION Cz TANK ID # TANK r 1 (� 3 MANUFACTURER �J L / � �j/! �/1 /� COMPARTMENTALIZED TANK ❑Yes No If'Yes', complete one page for each compartment. 14 0 rJ 1 JO) ,yt F��'7 (l GZ , ` /, !( / DATE INSTAL ED (Y TANK CAPACITY IN GALLONS`/(f NUMBER OF COMPARTMENTS Isle ADDITIONAL DESCRIPTION (Forlocal use only) Il. TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL 1a. REGULAR UNLEADED LEADED El5. JET FUEL (llmarked, complete Petroleum Type) ❑ 1b. PREMIUM UNLEADED :LO DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM 1c MIDGRADE UNLEADED GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) CAS # (from Hazardous Materials Inventory Pa9e) ❑ 4. HAZARDOUS WASTE (Includes Used Oil) 1 95, UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK E SINGLWALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM ,,,.....❑///1. (Check one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN // ❑ 4. SINGLE WALL IN A VAULT ❑ 99. OTHER TANK MATERIAL - primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC 5. CONCRETE 1195. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS FRP COMPATIBLE W/100% METHANOL 1199. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL- secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC 8. FRP COMPATIBLE W/100% METHANOL 1195. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON -CORRODIBLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING 114. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER Check one item on) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (Check one item only) El 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE (For kxal use only) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED (Check all that apply) 1. SPILL CONTAINMENT 1. ALARM 3. FILL TUBE SHUT OFF VALVE DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK (Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): IS UAL (EXPOSED PORTION ONLY) nAUTOMATIC El 5. MANUAL TANK GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) TANK GAUGING (ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING CONTINUOUS ATG - 10 ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING STATISTICAL INVENTORY RECONCILIATION (SIR) F ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑ 99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH'NERT MATERIAL? gallons ❑ Yes ❑ No CUPAFORM (4199) SS Formerly SWRCB Form B