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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> i (Oso Pages tank) <br /> Page _ o <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT $TS. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE /� <br /> (ClNck care Nem onry) ❑ T. PERMANENTLY CLOSED ON SITE �"I <br /> ❑3.RENEWAL PERMIT (Spealy Mann-/pzlaCN use omW (Spaay har,ge-/wbcaluu oMW <br /> ❑ B. TANK REMOVED d30 <br /> BUSINESS NAME(Gams as FACILITY NAME or DBA-Doinq Buvexaa As) FACILITY 10 a 1 <br /> 2 9 <br /> 4211 <br /> L TANK DESCRIPTION <br /> TANK ID k TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Ya ❑ No <br /> If'Yae.COmPIah aM P]ge for earllMmoeNnenl. ' <br /> DATE INSTALLED(YEAWMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Far bW Into OW <br /> IL TANK CONTENTS <br /> TANK USE 4M PETROLEUM TYPE <br /> ❑ I. MOTOR VEHICLE FUEL ❑1. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (pmw4eN,mmpah PffgNam Typs) ❑to. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NOWFUEL PETROLEUM ❑1c MOORAGE UNLEADED ❑ a. GASOHOL [3 99. OTHER <br /> Cl 3. CHEMIGLPRODUCT <br /> ❑ 6. HAZARDOUS WASTE(NICIWea COMMON NAME(hom Hazemous WWW.~oar,page) CAS a(Gom Hazamous Marenals Imwnmry page) <br /> USM ON <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK Cl 1 SINGLE WALL ❑ 3. SINGLE WALL VATH ❑ S. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Gwck one iMn wNW ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER Cl%. UNKNOAN <br /> ❑ 6. SINGLE WALL IN A VAULT ❑N OTHER <br /> TANKMATERIAL-Mons nk ❑ 1. SURE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑M. UNKNOYN <br /> (Gwen tar Nam.0y) ❑ 2. STAINLESS STEEL ❑a_ STEEL CLAD WIFlBERGU53 ❑ 8. FRP COMPATIBLE W ID M METHANOL [IN. OTHER <br /> REINFORCED PLASTIC(FRPI <br /> TANK MATERIAL-sxondary tank ❑ 1 BARE STEEL Cl 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WItDDIL METHANOL ❑N. UNIDKIPNN <br /> (COe oc orw Nem omy) ❑ 2. STAINLESS STEEL Cl d. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NONLORRODISLE JACKET ❑N. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ t. RUBBER UNED 113. EPDXY UNING ❑ 5. GLASS UNING ❑95. UNKNOANd33 DATE NSTALLED <br /> OR MATTING <br /> onsaam orW <br /> ❑ 2.ALKYO UNING ❑ d. PHENOUC UNING ❑ S. UNLINED ❑N. OTHER (Pa-mcom, <br /> OTHER PROTECTION <br /> IF ON ❑ 1. MANUFACTUREOCATHODIC ❑ 3. FIBERGLASS REINFORCER PLASTIC ❑%. UNKNOWN 134 DATE INSTALLED <br /> PROTECTION IF APPLIUBLE PROTECTION <br /> ❑ d. IMPRESSED CURRENT ❑N. OTHER (FwwvY uae omyl <br /> /CMck orls Nem oMW ❑ 2. SACRIFIGALANODE <br /> SPILLANDOVERFlLL YEAR INSTALL ED TYPE(F,,IaaW . W OVERFILL PROTECTION muiPMENT,YEAR INSTALLED <br /> (CMek aNfMf appal ❑ 1 WILL CONTAINMENT ❑ t ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2 DROP TUBE ❑ 2. BALL FLOAT ❑ d. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANKCOerX aN UNIX a IF DOUBLE WALL TANK OR TANK WTH BUDDER Gwpr ors,Nem ): <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) Cl 5. MANUAL TANK GAUGING INTO) ❑ t VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VAOOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICALINVENTORY NCILIA (MR)• ❑ B. TANK TESTING <br /> BIENNIAL TANK ❑N. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESDANTED M LAST USED(Y Y) ESTIMATED DUANTTlY OF SUBSTANCE REMAINING 4Wi I TANK FILLED WITH INERT MATERIAL7 <br /> galMNla ❑Yea o <br /> -fe, 23 <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />