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UNIFIED PROGRAM CONSOLIDATED FOR'NT <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> rfev pages per tank) <br /> \` Pape _ of _ <br /> TVPE OF ACTION 13 1.NEW SITE PERMIT 114. AMENDED PERMIT ❑ 5. CHANGE OFINFORMATION) yl e, TEMPORARY SITE CLOSURE <br /> ons%em PMi ❑ Z. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT ( j,,rsaam-rorbaaluro aM9 (Spsary grarps-rorrow um only) 138 TANKREMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Daitp SuNnsaa As) FACILITY ID% <br /> O� 1 <br /> t,u C*.. � r <br /> LOCATION WITHIN SITE(OprvzjD^4olntlJ 431 <br /> V <br /> 1.TANK DESCRIPTION <br /> TANK ID% TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yaa Na <br /> J�( � U�. if <br /> 'YaY,mmPlMe Prle PWs far each mmpanmsnl. <br /> DATE INSTALLED(YEA ) TANK CAPAC IN GALLONS NUMSEROFCOMPARTMENTS <br /> U hood <br /> ADDITIONAL DESCRIPTION(Farb uas orxy) <br /> It.TANK CONTENTS <br /> TANK USE 43 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (d marked,campbb PofmWm Typo) 11 lb. PREMIUM UNLEADED ❑ 3. DIESEL <br /> ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUECHEMICAL PETROLEUM ❑tc. MIDGRADE UNLEADED 13I. GASOHOL 1199, OTHER <br /> CHEMICA <br /> ❑ 3. L PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(/m . COMMON NAME(ham Hazar w MmiM lnwM q ) CAS i(hpm Hazanbw AMIerIM Inwn(aypage) <br /> Ua 00) <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (CMak one%em ay9 2 DOVBLEWALL EKTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANKMATERIAL-lw / BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 0 9. UNKNOWN <br /> (ClwN oris dem PrVy) ❑ 2, STAINLESS STEEL ❑4. STEEL CLAD WTtBERGLASS ❑ 8. FRP COMPATIBLE WI100%METHANOL 11 99. OTHER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-a%mWii,MnK 0 1 BARE STEEL ❑ 3. FIBERGUSS I PLASTIC ❑ B. FRPCOMPATIBLEW/190%METHANOL El 95 UNKNOWN <br /> (CAeakwrofbmanlyf ❑ 2. STAINLESSSTEEL ❑ 4. STEEL CADWIFIBERGUSS ❑ 9, FRP NON-CORRODIBLE JACKET El N. OTHER <br /> REINFORCED PUSTIC(FRP) 1110. COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING 13 1, RUBBER LINED ❑ 3. EPDXY LINING 11 [IN.COATING S. GLASS LINING . UNKNOWN433 DATE INSTALLED <br /> TA <br /> Pnsdem ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 8. UNUMED ❑99. OTHER <br /> Fwbw uea <br /> OTHER CORROSION 111 MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑B5. UNKNOWN 431 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑89. OTHER <br /> (CMck as dem only) <br /> El 2. SACRIFICIAL ANODE (Farlowl we only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(FwbcN use Dory) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CmeckWMat apply) ❑ 1. SPILLCONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SMUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALLFLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> W. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply) TIF DOUBLE WALL TANK OR TANK WITH BUDDER(Che[k Pyre ikmcKWl' <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. 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. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 4. STATISTICALINVENTORY RECONCILIATION(SIM). ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING 11 N. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PUCE <br /> TANK FILLED WATH INERT MATER AL? <br /> ESTIMATED DATE UST USED(YRAICIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 <br /> 9allms ❑Yea 11 No//��/\ <br /> q� V_ 41 � <br /> CUPAFORM(4/99) Fcrr dy SWRCB Fom B <br />