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UNIFIED PROGRAM CONSOLIDATED FORM V <br /> . TANKS uj.Wn <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 6 -k-016 <br /> (17wo WRQ Ila ) <br /> Page_of_ <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 4.AMENDED PERMITar5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. <br /> m <br /> (Clack.hewJy) [33.RENEWAL PERMIT /1/Q4i)C-4 qa ❑ 7.PERMANENTLY CLOSED ON SITE <br /> (Specify .oc) (Sp w-.0 ❑ 8.TANK REMOVED <br /> BUST.NAME IS.ee.FACILITY NAM,,.DBA-nous Basinea Aa) 3. FACB.Il'Y ID: 1. <br /> Y r✓T'0 Aa GAG ? g <br /> 01 loll I I <br /> LOCATION WITHIN SITE(opmeeo 431' <br /> +: I.TANK DESCRIPTION''" <br /> ` en}inchidmg buildings and lapdmarks'sball be submitted to the local agency.) <br /> TANK ID# 432- TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes No 434. <br /> 1a S0W;S3j 7e us co DATE INSTALLED 433. TANK CAPACITY IN GALLONS 4M 1 NUMBER OF COMPARTMENTS <br /> 437. <br /> (YEAR/MO) 212-9 7 121 Bex <br /> ADDITIONAL DESCRIPTION(Fe,bale only) 433, <br /> TAN <br /> USE 439 PETROLEUM TYPE 440. <br /> W. MOTOR VEHICLE FUEL ❑1 REGULAR UNLEADED ❑2. LEADED [IS. JET FUEL <br /> Of<hxkM eongWePcaokam Ty.) ly, PREMIUM UNLEADED [3 3. DIESEL [3 6. AVIATION GAS <br /> ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [3 4. GASOHOL ❑99.OTHER: <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(ham Hazardous Mazedaly lnvmbry page) NI. CAS#(6o.Na. mataiaYtme paae) 441 <br /> ❑ 4. HAZARDOUS WASTE <br /> oacktl Used Oip <br /> ❑ 95.UNKNOWN <br /> CONSTRUCTIO <br /> TYPE OFTANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM M3. <br /> (CheckoneitemoWy) MEMBRANE LINER 095. UNKNOWN <br /> . <br /> MI"BOUBLE WALL 4 SINGLE WALL IN A VAULT El 99. OTHER <br /> TANK MATERIAL-pmmary talk ❑1. BARE STEELLVf2l. FIBERGLASS/PLASTIC 05. CONCRETE 095.UNKNOWN N4. <br /> (Chet ao<aemonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/PIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: <br /> ORCFD PLASTIC W/100%METHANOL <br /> TANK MATERIAL-secondary tack ❑I. BARE STEEL W. FIBERGLASS/PLASTIC 8. PRP COMPTIBLE W/IOo%METHANOL 0 95.UNKNOWN M5. <br /> (Check one item only) ❑2. STAINLESS STEEL[14. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> 5. CONCRETE <br /> TANK INTERIOR LINING L RUBBER LINED ❑3.EPDXY LINING ❑S.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED a7. <br /> OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER <br /> Check ane item only) <br /> OTHER CORROSION ❑1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC El 95.UNKNOWN 44g. DATE INSTALLED 449. <br /> PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER <br /> f Ecable 2.SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED 430. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 451 <br /> (Check a0 that apply) [11.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE_ <br /> [12.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT <br /> 3.STRW"PLATE <br /> H SINGLE WALL TANK 453. IF DOITBLE WALL TANK OR TANK WITH BLADDER 154. <br /> (Check all that apply) (Check one Stam only) <br /> ❑I.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑I.VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3.CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING <br /> ❑4. STATISTICAL INVENTORY RECONCILIATION [:18.TANK TESTING <br /> (SIR)+BIENNIAL TANK TESTING 099. OTHER <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 433' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 451 <br /> gallons [IYes [I No <br /> UPCF hwfwm b.(1/99)-.1/4 http://www.unidocs.org Rev.02/16/00 <br />