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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> P+ge _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGEOFINFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (CMLk arra iNm wily) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT )Spay na+onb/Iacal ur orYyl (Spay rJM/pa-lwlpuluas aHyl ❑ S. TANK REMOVED 430 <br /> BUSINE NAME(SMm n FAClpTY NAME w DSA.GoiN Busimu A+) FACILITY ID 9 <br /> LOCATION WTHIN SITE K)peoMg 431 <br /> O <br /> I.TANK DESCRIPTION <br /> TANK IDO c / TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yaa o <br /> �� 7/ //�/�'_✓�j�r If'Yai,compete one papa for axt� +nmem. <br /> DATE INSTAU`hU('YEAMPR/M ))1� , TANe CAPACITY IN GALL O NUMBER OF COMPARTMENTS <br /> q=T10NAL DESCRIPTION(F I=N use nary) <br /> 11.TANK CONTENTS <br /> TANK USE 433Elb. <br /> PETROLEUM TYPE <br /> ❑ 1 MOTOR VEHICLE FUEL LAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (hnRlkaa,ca^pMl°PNrvhlml Typa) UM UN LEADED ❑ 3. DIESEL ❑ 5. AVIATION FUEL�. NON-FUEL PETROLEUM ADE UNLEADED ❑ 4. GASOHOL OTHER �J��� <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(Ifwn H+s+mlau+Mafsa+k Mhmwy pg+) CAS IF(ft.Masardous MafaMU lmamory Papa) <br /> ❑ 4. HAZARDOUS WASTE(ImJUWS <br /> WINI OA) <br /> rl 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK _ SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> EXTERIOR MEMBRANE LINER 0 95. UNKNOWN <br /> (CMFk oro nem any) ❑ 2. DOUBLE WALL 0 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-pdnary Mok 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> fOh+ak ori gem Dory/ ❑ 2. STAINLESS STEEL ❑A. STEEL CLAD WIFISERGLASS ❑ B. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-Ma My MM 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. FRP COMPATIBLE W/100%METHANOL 095. UNKNOVIN yj/ <br /> (CAKk am aama w ❑ 2. STAINLESS STEEL 0 4� STEEL CLAD IRMIR(FRP) ❑ 9_ FRP NON.CORROOI LLE JACKET P. OTHERJ}[Jy�L_ <br /> ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> DATE INSTALLED <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNKNOWN433 <br /> GRCWTING <br /> ❑ 2. ALI(YD LINING ❑ 4. PHENOLIC LINING UNLINED ❑98. OTHER FwlaaN use <br /> Check ons Mm DATE INSTALLED <br /> OTHER CORROSION ❑ t. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION A. OTHER <br /> ❑ 4. IMPRESSED CURRENT (Fwbcal----w <br /> (CMck wrift.owy) ❑ 2. SACRIFICIAL ANODE <br /> YEA0.INSTALLED TYPE(Fprlwaluaawtly) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILLANDOVERFILL n <br /> (CMak+FfMfaAPIW) 0 1 SPILL CONTAINMENT ❑ 1. ALARM - 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT__ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> JV. TANK LEAK DETECTION <br /> IF DOUBLEWALL TANK ORTANKWITH BLAG,: kom dem on <br /> rZA�O"!FC!TANK <br /> LE WALL TANK CMCk 40 IMI <br /> VISUAL PORTION ON <br /> Jy 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ICTANK GAUGING(ATG) 8. VADOSEZONE ❑ 2. CONTINUOUSINTERSTITIALMONITORING <br /> OUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> L INVENTORY RECONCILIATION(SIR)� ❑ 8. TANKTESTING <br /> TANK TESTING ❑gg, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE UST USED(VRIMOIDAY) <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED NTH INERT MATERIAL') <br /> g+ppna ❑Yaa No <br /> 5- <br /> �, Formerly SWRCB FOMB <br /> CUPAFORM(4199) J'�(rA(,/r <br /> �r <br />