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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS -TANK PAGE 1 TYPE OF ACTION Ell. NEW SITE PERMIT ❑ 4. AMENDED PERMIT (Check one item only) ❑ 3. RENEWAL PERMIT (Specify, reason - for local use only) // CHANGE OF INFORMATION) (Specify change - for local use only) TANKS (tiro pages per tank) Page _ of ❑ 8. TEMPORARY SITE CLOSURE ❑ 7. PERMANENTLY CLOSED ON SITE ❑ 8. TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) FACILITY IDA 1 LOCATION WITHIN SITE ( ptionall _ 431 I. TANK DESCRIPTION TANK ID A TANK % MANUFACTURER // "jam PARTMENTALIZED TANK ❑ Yes A No If'Yas', complete one page breach partment. . J e� //i y/�rc� I GC / ( / DATE INSTALLED (Y O) TANK CAPACITY IN/GALLONS NUMBER OF COMPARTMENTS A,) (/ I S ADDITIONAL DESCRIPTION IPTION (Forlocal use only) It. TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL C1 la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (I/marked, complete Petroleum Type) tb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM El J.MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (hem Hazardous Materials Inventory page) CASA (from HazardousMaterials Inventory page) ❑ 4. HAZARDOUS WASTE (Includes Used Oih 095, UNK 111. TANK CONSTRUCTION TYPE OF TANK ❑ 11. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) X2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL - primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS / PLASTIC 055, CONCRETE ❑ 95. UNKNOWN (Check one Hem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS o. FRP COMPATIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL - secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS / PLASTIC B. FRP COMPATIBLE W/100% METHANOL ❑ 95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 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 ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER (Cheek one item only) (For We/ use only) OTHER CORROSION ❑ 1MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE . PROTECTION ❑ 4. IMPRESSED CURRENT ❑ 99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (Forbcal use only) SPILL AND OVERFILL q q YEAR INSTALLED TYPE (For local use only) OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED (Check all that apply) 1. SPILL CONTAINMENT 1. ALARM 3. FILL TUBE SHUT OFF VALVE 2. 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). ❑ 1, VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MTG) ❑ VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) + ❑ 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 INERT MATERIAL? gallons 1 ❑ Yes ❑ No CUPAFORM (4/99) 'ES Formerly SWRCB Form B