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- NI-AvkAta Zp2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM D g\g�o3 <br /> O-\ TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAG <br /> Q/p 3(two pages per tank) <br /> Page L_of <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION JQ_6 TEMPORARY SITE CLOSURE <br /> (Chcckaee itamoaly) - ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Spaify rmswr-fm heal uae only) (Spaifytenan-farlowluaeonty) ❑ 8 TANK REMOVED 4" <br /> BUSINESS NAME(Sameas FACILr NAME DBA-DMipg Buvi.M) FACILITYID: 1 <br /> - 08 ' f UU <br /> LOCATION WITHIN SITE(Op.1);23[� C F Ci9 431 <br /> L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 433 I TANK MANUFACTURER 633 COMPARTMENTALIZED TANK ❑Yea; No ase <br /> V'Inowe\ u-Ye:mmptae oMpage r r ex6aompmmnmL <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> V�vww A 0000 � <br /> ADDITIONAL DESCRIPTION(For weal me any) 438 <br /> It.TANK CONTENTS <br /> � TANK USE 439 PETROLEUM TYPE <br /> a../µ saa <br /> t1> MOTOR VEHICLE FUEL K['a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> (IfmahW ra^Plele Pewwum Type) ,r❑\I`b. PREMIUM UNLEADED 03. DIESEL 06. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME Isom Haeaolaaa Maadala taventory page) 661 CAS#(nom Halardaoa M o mia Inventory page) 442 <br /> ❑4. HAZARDOUS WASTE <br /> (IncwdeaU Oil) <br /> ❑95.UNKNOWN <br /> III. TANK CONSTRUCTION <br /> TYPE OF TANK U 1. SINGLE WALL U 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 4a3 <br /> (Click am imm only) EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC U 5. CONCRETE 4W. UNKNOWN 4a <br /> (CTa4oncim wy) ❑2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W11001%METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-aaoadmyta1. BARE STEEL U3. FIBERGLASS/PLASTIC U 5. CONCRETE 5. UNKNOWN 445 <br /> (Check arc item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 171.RUBBERLINED 3.EPDXY LINING Ll 5.GLASS LINING CK5.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Chale cam imm only) .,,,,� (For local uae only) <br /> OTHER CORROSION C11 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC &5 UNKNOWN ' DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> (Chat omiwp oat') (12 SACRIFICIAL ANODE (Fa local oe only) <br /> SPILL AND OVERFILL YEARINSTALLED 450 TYPE Bent me ant') 451 OVERFILL PROTECTION EQUIPMENMYEAR INSTALLED 4sz <br /> (Chale all wtappy) I6,I SPILL CONTAINMENTY/'DQNf\ WAA <br /> .} ALARM ❑3 FILL TUBE SHUT OFF VALE E <br /> R2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT <br /> STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A description ofd%,mooir ,pogromahan be sukora N to ncolocal ageseyj <br /> IF SINGLE WALL TANK(Chakan en apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4s4 <br /> (Checkaxiremanly) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 9,2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ®.T MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING El 99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO(DAY) 455 ESTIMATEDQUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH, 'INERT MATERIAL? 457 <br /> gallons LNy. ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />