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L/ <br /> �sy <br /> UNIFIED PROGRAM CONSOLIDATED FORM tNNKS <br /> P <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 ` <br /> Papa _ al _ <br /> TYPE OF ACTION W-IMSITEPERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) [38. TEMPORARY SITE CLOSURE r8 <br /> tch k eM aem onyt 0 7. PERMANENTLY CLOSED ON SIT <br /> ❑3.RENEWAL PERMIT (SFezJN neaon-lorkral uas oMy) (SFeay Marga-brhW use erY» ❑ S. TANK REMOVED CID <br /> BUSI SS NAME(Same ex FACILITY NAME or DBA-DpPp 9usNexx M) FACILITY 10 F 1 <br /> LOCIMON-WTHIN SITE(Optlone9 <br /> 1.TANK DESCPoAOIN <br /> TAN 100 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ Na <br /> _ � %k� 11'Yu.comDleb ma Da9e breaM eempaNmnL <br /> TEINSTALLED(YEARAIOI TANKCAPACITYINWLLONS {� NUMBER OF COMPARTMENTS _ <br /> ADDITIONAL DESCRIPTION(ForbW uae-ray) <br /> 11.TANK CONTENTS <br /> TANK USE a32 PETROLEUM TYPE <br /> ❑ 1. MOTORVEHICLEFUEL Q 1e, REGULAR UNLEADED 0 2. LEADED ❑ S. JET FUEL <br /> (If Aw,,c.,Wbm Paholeum TyP) ❑1h. PREMIUM UNLEADED ❑ 3. DIESEL 0 6, AVIATION FUEL <br /> 0 2, NON-FUEL PETROLEUM Q to MIDGRADE UNLEADED ❑ C GASOHOL [IN OTHER <br /> 03 EMICAL PRODUCT COMMON NAME(ham Hezartlous Manaalx Im+nforype9s) CAS a(hom Hezamlous MaMRala ln~10gpape) <br /> ❑ HAZARDOUS WASTE ry�x <br /> Us 0117 <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1, SINGLE WALL 03. SINGLEWAULWTH Q 5, SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> EXTERIOR MEMBRANE LINER IQW UNKNOWN <br /> (CRack oro Bsm Dory) ❑ 2. DOUBLE WALL ❑ 4, SINGLE WALL IN A VAULT ❑W. OTHER `�T� <br /> TANK MATERIAL-Primary Mnk ❑ 3. FIBERGLASS/PLASTIC ❑ S. CONCRETE *-I UNKNOWN <br /> ❑ 1. BARE STEEL !! <br /> (Check orro ieem orVyt ❑ 2. STAINLESSMEEL 04, REINFORCEDLCI_APUBERGLASTIC PS ❑ 8. FRP COMPATIBLE W100%METHANOL Q99.OTHER <br /> TANK MATERIAL-aer dM bnk (1 t. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC 08, FRP COMPATIBLE WmM%METHANOL . UNKNOWN <br /> JACKET [IN.OTHER <br /> (Check one item oNy) 0 2. STAINLESS STEEL 0 4,REINFORCED PLASTIC STEEL CLAD LASS) ❑ 9 COATEDWWCORRODIBLE <br /> ❑ STEEL <br /> 5.CONCRETE <br /> . DATE INSTALLED <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED 0 3, EPDXY LINING 0 5,GLASS LINING 095. UNKNOWNA33 <br /> OR COATING -❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING 0 5. UNLINED [10. OTHER (ForbWuaa <br /> - <br /> AxkornkemonDATE INSTALLED <br /> OTHER CORROSION ❑ I. WNUFACTUREDCATHODIC 0 3, FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN K31 <br /> PROTECTION IF APPLICABLE PROTECTION ❑ l IMPRESSED CURRENT 099. OTHER (Forbc+l uaa any) <br /> (Check Dna ibm-*) 0 2. BACK .CIALANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILLANDOVERFILL YEAR INSTALLED TYPE(Ferbcsl uss ortly) <br /> (CM aftlaPPM Q 1. SPILLCONTAINMENT Q 1. ALARM 0 3, FILLTUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE 0 2. BALL FLOAT_ 0 a. EXEMPT <br /> Q 3. STRIKERPUTE <br /> N:TANK LEAK DETECTION - <br /> IF DOUBLE WALLTANK OR TANK WITH BLADDER(Check one item onM: <br /> IF SINGLE WALLTANK Chet atl fMl a ): 0 1. VISUAL.(SINGLE WALL IN VAULT ONLY) <br /> ❑ J, VISUAL(EXPOSED PORTION ONLY) 0 & MANUAL TANK GAUGING(MTG) <br /> 0 2. AUTOMATICTANKGAUGING(ATG) ❑a. VADOSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ' <br /> (1 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. S,AnSTICALINVENTORY RECONCILIATION(SIR)• ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING QB9. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MdDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 635 TANK FILLED WITH INERT MATERIAL] <br /> 0 Yes ❑No <br /> Former y SWRCB Form B <br /> CUPAFORM(4199) <br />