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UNIFIED PROGRAM CONSOLIDATED FORMTANKS <br /> AGE 1 <br /> UNDERGROUND STORAGE TANKS -TANK P <br /> (Am pages per Mnk) <br /> Page _ N <br /> TYPE OF ACTION 111.NEW SITE PERMIT D 1. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ,�.❑rsa11 B. TEMPORARY SITE CLOSURE <br /> (Chack ane Atm a tY) Z'1?. PERMANENTLY CLOSED ON SITE <br /> D3.RENEWAL PERMIT (3pecttyreason-brloal usr ovAy) (Sperry Gurpa-brlocal uss Doty) ❑ S.TANK REMOVED 130 J <br /> BUSINESS HANE(Sarin ae FACILITY NAME or OM.Ggh�,Bwinaea As) <br /> FACILITY 10t >E+ t <br /> SOW Lt�J 7Boo S 0f, %uG <br /> L TI INS E pbo�^�(/ + 1 <br /> . r�wl \✓Vl <br /> I.TANK DESCRIPTION <br /> TANK IDA TANK MANUFACTURER COMPARTMENTALIZE D TANK ❑ Vas <br /> II'Yai,apnplNe we page heacn runpanment. <br /> UOMP <br /> GATE INSTALLED(YEARJMO) TANK CAPACITY IN GALLONS MBER OF CARTMENTS <br /> Ry . l 1?eibr� R.Efv4eA 4co ui u u < o G <br /> ADDITIONAL DESCRIPTION(FDrI to Only) <br /> IL TANK CONTENTS <br /> ,�,,A <br /> TANK USE 132 ,..I PETROLEUM TYPE <br /> A-t MOTOR VEHICLE FUEL LI la. REGULAR UNLEADED -- __""'' /yy1 ❑ 2. LEADED ❑ 5. JET FUEL <br /> (tt maM4 campara PelmMYm TYP0 911, PREMIUM UNLEADED r {� 03. DIESEL ❑ S. AVIATIONFUEL <br /> 02. NON-FUEL PETROLEUM ❑tc MIDGRADEUNLEADED YYY ❑ d. GASOHOL ❑99. OTHER <br /> 0 3.CHEMICALPRODUCT COMMON NAME(M1om HazaNwt MaMANa lnventarypape) CAS A pmm HetaMOus Matenals Inventory Page) <br /> 0 1. HAZARDOUS WASTE(IrM - <br /> UaM 01) <br /> 095 <br /> NGWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 'QL 1 SINGLE WALL 03. SINGLE WALL VATH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Chick mu dem ono? 0 2. DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> D 1. SINGLE WALLIN A VAULT 0 N. OTHER <br /> TANK MATERIAL-pNlury tank 1. BARE STEEL 0 3. FIBERGLASS I PLASTIC 0 5. CONCRETE 095. UNKNOWN <br /> lCtuck erre Bem *) ❑ 2. STAINLESS STEEL 11 L STEEL CLAD WIFIBERGLASS 0 S. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REINFORCED PLASTIC FRP) <br /> TANK MATERIAL-Mcordar,Mnk 0 1 BARE STEEL 0 3. FIBERGLASSIPLASTIC D B. FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (Clack..avm ONY) 0 2. STAINLESS STEEL 11 0. STEEL CLAD W/FIBERGLASS 0 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> 0 5. CONCRETE � <br /> TANK INTERIOR LINING D 1. RUBBER LINED 11 3. EPDXY LINING 11 5. GIASS LINING 44S. UNKNOWNA33 DATEINSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ 1. PHENOLIC LINING ❑ B. UNLINED 099. OTHER Fork¢al uaso <br /> DhxA arM iMm <br /> DATE INSTALLED <br /> OTHER CORROSION 11 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC K95. UNKNOVM 131 <br /> PROTECTION IF APPLICABLE <br /> PROTECTION 01. IMPRESSED CURRENT 1199. OTHER <br /> fch ova tem'-w D 2. SACRIFICIAL ANODE (ForbcN use oMy) <br /> SPILL AND OVERFILL o✓K►e�.oJ YEAR INSTALLED WPE(ForbcN use OMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check 0 Mal appy) ❑ 1 SPILL CONTAINMENT 11 1. ALARM 0 3. FILLTUBESHUTOFFVALVE <br /> 11 2, DROPTUBE 0 2. BALL FLOAT 0 a. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CARk NI Nut 18& IF DOUBLE WALL TANK OR TANK WITH BLADDER Check erre Aem <br /> OW <br /> 01, VISUAL(IDPOSEOPORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLEWALL IN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSEZANE 11 2. CONTINUOUS INTERSTITIALMONITORING <br /> 11 3. CONTINUOUSATG D T. GROUNDWATER 0 3. MANUALMONITORING <br /> 11 1. STATISTICALINVENTORYRECONCIUATION(SIR) 0 8. TANKTESTING <br /> BIENNIAL TANK TESTING 1199. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED IYRMOIDAYI ESTIMATED QUAN�TIT,YyOOF SUBSTANCE/j�EMAINING 135 TANK FILLED WITH INERT MATERIAL? yy�.�� <br /> 1q5� 1.0KOKtipLdV galea 0Yea 11NO V0 r <br /> -r��(�5e- TL►�,�1<S w e2.� 0 <br /> LU A <br /> � <br /> 8 <br /> CUPAFORM(<%59�� tFolRlerly SWRCB Form <br /> TA�UI�S u� b <br />