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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PA494 I <br /> (two pages per tank) <br /> Pa¢e <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT 115 CHANGE OF INFORMATION 0,6 TEMPORARY SITE CLOSURE -X--or <br /> (Check onehem only) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWAL PERMIT (Sµciymwn-Torlocaloneenty) (Spsiy rceeon-for bcel uu oelY) ❑ 8 TANK REMOVED <br /> Ua <br /> BUSINESS NAME(Samee FACMTNAMEor DBA-Doing BwiM Aa) FACILIIYID: 1 <br /> ' FA <br /> 0Y <br /> LOCATION WITHIN SI (opuennq <br /> en <br /> 1.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 /> ANK m#/ 432 TANK MANUFAR 433 COMPARTMENTALIZED TANK ❑Yes No 434 <br /> N fN60uoLq;L V/1 CTUREIr^Ye-,omoi,Ioo--p.g f ..h,00gmnnent <br /> DATE INSTALLED(YEAR/MO) 435 1 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> Vr\tnmun _4 <br /> ADDITIONAL DESCRIPTION(Fe 1.1 one my) 439 <br /> IL TANK CONTENTS <br /> � <br /> ` TANK USE 439 PETROLEUM TYPE sa <br /> p(J -MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑�2l. LEADED ❑5. JET FUEL <br /> 0rmaiked complete Pewkum Type) <br /> [I lb. PREMIUM UNLEADED $4 DIESEL <br /> ❑6. AVIATION FUEL <br /> [12.NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑9P9.OTHER <br /> ❑3. CHEMICAL PRODUCT COMMON NAME (c m xae m Mand s mvmm y p ge) 401 CAS#If.w .Mar dnl mummy,eze) a42 <br /> ❑4. HAZARDOUS WASTE <br /> (Ioolude Used Od) <br /> ❑95.UNKNOWN <br /> 111. TANK CONSTRUCTION <br /> TYPE OF TANK U I. SINGLE WALL U 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> ((Meckmeilemmly) EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 02. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-Primary eK U I. BARE STEEL U 3. FIBERGLASS/PLASTIC U 5. CONCRETE . UNKNOWN 4Z <br /> (C kone imn only) ❑2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/I00%METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-seconduyw 0 1. BARE STEEL U 3. FIBERGLASS/PLASTIC 0 5. CONCRETE . UNKNOWN w5 <br /> (Llak one item only) 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPUBLE W1100%METHANOL 099.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 0 1.RUBBER LINED U 3.EPDXY LINING 0 5.GLASS LINING 5.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (C ooercmedy) (Fe total one wly) <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC Y�UNKNOWN aaa DATE INSTALLED Us <br /> PROTECTION IF APPLICABLE- PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER <br /> (C one leen my) ❑2 SACRIFICIAL ANODE (Fennel ee noy) <br /> SPILL AND OVERFILL YEARINSTALLED p �450 TYPE(i oseenly) 451 OVERFILL PROTECTION EQUIPMENTMEAR INSTALLED 452 <br /> ([heck allow apply) �ISP[LL CONTAINMENT V1�VTa0HJn J21.11 ALARM ❑3 FILL TUBESLE <br /> TUBE SHUT OFF VALVE <br /> [4Qa2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT <br /> [rJ-STRIKER PLATE <br /> V.TANK LEAK DETECTION(A description ofNe vwnimrivgpragmn ahan k submine t m me loel agency.) <br /> IF SINGLE WALL TANK(Check Al Out apply) 451 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (le one igen only) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) Cl 6 VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING <br /> 0.3 CONTINUOUS ATG ❑7 GROUNDWATER ]MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING 0 9 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED Q rITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> Z-OZ (� gallons Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />