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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page j_of TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ,Q,_6 TEMPORARY SITE CLOSURE (Check ooe ilmr any) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Sp ifyaeason-forlocalu0000ly) (Specifyreaon-forbcaloseonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(SnnenFACB.DYNAWwDBA-Doing Hwuwos Ar) FACILITYID: 3 n LOCATION WITHIN SITE(opaovr0 al 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.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ($No 4M ViV%VW(\ If"Yn c^^P one page fm each conWammrni DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436NUMBER OF COMPARTMENTS 437 Uf\VoA0W 10000 I ADDITIONAL DESCRIPTION(For lane uee Dory) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE a4n MOTOR VEHICLE FUEL \1. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL pfmuted agnpkrc Petmleum Type) �❑Ib. PREMIUM UNLEADED 03. DIESEL 06. AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (noon Haeareoty Maunri trvenmry page) 441 CAS#(aon Heaaadour marerula lnvrnrory page) 0 4. HAZARDOUS WASTE (IMWa Dred Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 0 I. SINGLE WALL U 3. SINGLE WALL WITH U S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check armi only) EXTERIOR MEMBRANE LINER 095. UNKNOWN DOABLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANKMATERJAL-prftn y nk U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC U 5. CONCRETE . UNKNOWN 444 (Omck Doe iron oay) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%.METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-saondar,mrk 0 I. BARE STEEL U 3. FIBERGLASS/PLASTIC U 5. CONCRETE 5. UNKNOWN 445 (check ove rose only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/IW/.METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING U 1.RUBBER LINED U 3.EPDXY LINING U 5.GLASS LINING CKS,UNKNOWN 4C6 DATE INSTALLED 441 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one ilom only) .r,,�( (Forla .only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC &S UNKNOWN DATE INSTALLED 499- PROTECTION 49PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (checkoveaenonh) ❑2 SACRIFICIAL ANODE (For bod use only) SPILL AND OVERFILL , YEARINSTALLED y450 TYPE pool use anlY) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chuk Vl lhet apply) Oki SPILL CONTAINMENT vy tvw1 ..((.a'' A�'.IbU'`Il /Jr ALARM ❑3 FILL TUBE SHUT OFFFVALVE $k�2DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT 0 a1STRIKER PLATE IV.TANK LEAK DETECTION(Adercriptioa orwe mvaibnvgprogrun anon he sohwim4 to Lae 1on1 agency.) IF SINGLE WALL TANK(check,11 wn apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Cn k one sero roily) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 0,2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ®d MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING 0 9 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATEDQUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 Z-a�i (J gallons &Y. ❑ No UPCF(12/99 revised) IO Formerly SWRCB Form B