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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 TANKS <br /> (Mn pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION L11.NEW SITE PERMIT 134. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) e. TEMPORARY SITE CLOSURE <br /> (CMN!9m Mm oNy) <br /> 113.RENEWAL PERMIT (Sw4+N Mare ❑ T. PERMANENTLY CLOSED ON SITE <br /> oM9 (Sprdy cMnpe-br kKW usa oMN ❑ e. TANK REMOVED 430 <br /> BUSINESS NAME(Sams as FAGuY NAME w DBA-DOM,BuNMn Aa) FACILITY ID i 1 <br /> - /vk-- <br /> LOCATION WITHIN SITE(OPkDrMi 431 <br /> 72.0o S . <br /> TANK 10 i TANK MANUFACTURE0. I.TANK DESCRIPTION <br /> COMPARTMENTALIZED TANK ❑ Yn No <br /> / - vK It Ye4',mmpMle onapaw w a sIn oompanmenf. <br /> DATE INSTALLED(YEAR,MO) TANK CAPACITY IN GALLONS NUMBEROFCOMPARTMENTS <br /> vrC p <br /> ADDITIONAL DESCRIPTION(Forlocal use&*) <br /> 11.TANK CONTENTS <br /> TANKUSE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (MmarFq,compete Pao T"") 1D. PREMIUM UNLEADED ❑ 3. DIESEL ❑ <br /> ❑2. NON-FUEL PETROLEUM e. AVIATION FUEL <br /> 01c MIDGRADE UNLEADED ❑ 4, GASOHOL ❑W. OTHER <br /> ❑ 3.CHEMICAL PRODUCT <br /> ❑ 4. H RDOUS WASTE(InrJWes COMMON NAME(horn HauMous MsbrNla Inrenrwy paps/ GAS i(/mm Hesanlous Mebaals Inrentory Pa9c) <br /> Uaad Olq <br /> 0 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3, SINGLE WALL WITH 0 5, SINGLE WALL WITH INTERNAL BI-ADDER SYSTEM <br /> (Owl ons Mm onN 0 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195 UNKNOWN <br /> ❑4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank 1 BARE STEEL 0 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 13 95, UNKNOWN <br /> IcM o wHa/nwM9 ❑ 2. STAINLESS STEEL 04. STEEL CLAD WNISERGLASS ❑ e. FRP COMPATIBLE W/1W%METHANOL 099. OTHER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-saronJ•MY Wk 0 1 BARE STEEL 0 3, FIBERGLASS I PLASTIC ❑ S. FRP COMPATIBLE W/11W16METHANOL 095. UNKNOWN <br /> (CDeck wM Mem only) 0 2. STAINLESSSTEEL ❑ 4. STEEL CUD WNIBERGUSS ❑ 9. FRP NOWCORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> 1110. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING 111, RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS UNING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING 114. PHENOLIC LINING 0. UNLINED ❑99. OTHER <br /> Circle OItem (ForlocssIumssW <br /> C <br /> OTHER CORROSION C11. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC 0 95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 0. IMPRESSED CURRENT ❑99. OTHER (� <br /> (C�fO°a M°O^D•J ❑ 2. SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwksosiussol OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CAeck aM Mat apply) 1. SPILLCONTAINMENT <br /> ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE 0 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> W. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CMck all theta ): IF DOUBLE WALL TANK OR TANK WITH BLADDER(CMck om demo ): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) 0 e. VADOSE ZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG 0 T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 9. TANKTESTING <br /> BIENNIAL TANK TESTING <br /> [IN. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMODAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT WTERIALT <br /> gallons ❑Yee ❑No <br /> q,X-Rq ,�p <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br /> `, J <br />