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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Mn Page.per tarp <br /> Page <br /> TYPE OF ACTION ❑L NEWSITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) VB. TEMPORARY SITE CLOSURE <br /> (LhM orw bm arAY) 11 ?. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SpKM,Mann-SNIacMwsoFAY) (SP ,MarNa-� ❑ e. TANK REMOVED dap <br /> BUSINESS NAME(Sams In FACILITY NAME w DBA-Doing Busirraa AN FACILITY ID e 1 <br /> 0 <br /> LOCATION HIN SITE OpUmW 431 <br /> 1.TANK DESCRIPTION <br /> TANK 10e TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Y. No <br /> )5 .G I -01 U lc_ It-Yee',campMle one pps tw each camPaaMr1. <br /> DATEINSTALLED(YEARANKCAPACIT <br /> IO) TAYINGALL S NUMBER OF COMPARTMENTS <br /> j Z 00 <br /> ADDITIONAL DESCRIPTION(Forbcal um mW <br /> N.TANK CONTENTS <br /> TANK USE 43B PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (s-a .,mmpma Psso Type) �lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NOWFUELPETROLEUM ❑tc MIDGRADE UNLEADED ❑ 4. GASOHOL 110. OTHER <br /> ❑ 3.CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(InclWea COMMON NAME Mm Nssartlpua MaMMk Inwmarypepe) CAS•(ham HAZalnOYS Mafenala InwMoryppt) <br /> uaal an <br /> UL TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Cheek ora Asm arty) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER X95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT [IN. OTHER <br /> TANKMATERIAL-pnmary Wlk / BARE STEEL ❑ 3. FIBERGUSS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWW <br /> IcJ wa Aem wNy) ❑ 2. STAINLESS STEEL 114. STEEL CUD W/FISERGUSS ❑ S. FRP COMPATIBLE W/100%METHANOL W. OTHER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-aecorMay lmk 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ e. FRP COMPATIBLE W11M%METHANOL 95. UNKNOWN <br /> (Check on Atm oMy) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD WIFIBFRGIASS ❑ 9. FRP NON-CORRODIBLE JACKET W. OTHER <br /> REINFORCED PLASTIC(FRP) 1110, COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING COATING 3. EPDXY LINING O 1195. N 13 1. RUBBER LINED ❑ \ 5. GLASS LINING 95. UNKNOV33 GATE INSTALLED <br /> TA L`^J <br /> ens Asm 11112. ALKYD LINING 4, PHENOLIC LINING B. UNLINED ❑99. OTHER <br /> OTHER FwlwM uas <br /> C <br /> PROTECTION <br /> 111 MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWW 434 DATE INSTALLED <br /> PROTEN IF APPLICABLE PROTECTION <br /> hxkena Atmonry) ❑ 4. IMPRESSED CURRENT 11 W. OTHER <br /> (C <br /> ❑ 2 SACRIFICIALANODE (Fwhceluu orlN9 <br /> SPILLANDOVERFILL YEAR INSTALLED TYPE(Forbcal. W OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CBaaka fw.ppl)9 ❑ 1. SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE_ <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> . IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that e p): IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check one Aem only): <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ e. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CORMNUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 4. STATISTICALINVENTORYREOONCILIATION(SIR)+ ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING <br /> [IN. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRAtOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> Battens ❑Na <br /> 11 Y. <br /> CUPAFORM(4/99) Formerty SWRCB Form B <br />