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o <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANI <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Aw pages per nk) <br /> Pape of <br /> TYPE OF ACTION ❑1.NEWSITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGEOFINFORMATIONI <br /> (Check ❑ S. TEMPORARY SITE CLOSURE <br /> oils Aam oryg <br /> ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (s_p_fy aai-brkgluas <br /> wY1? (Spxly ciMnps-brbcal vas only ❑ B. TANK REMOVED 130 <br /> BUSINESS NAME(Same ae FACIUTY NAME w DBA-DNN BUainaM Ae) FACILITY IDP 1 <br /> t�ll�x-►JCS.. <br /> LOCATION WITHIN SITE(OpftW <br /> I.TANK DESCRIPTION <br /> TANK ID♦ O TANKMANUFACTURER LdAPARTMENTALI2ED TANK ❑ Ve4 ElN. <br /> II'Yee.c PMte one Pape W aaMl mmpeKnwnl. <br /> DATE INSTALLED(YEARMO) TANK CAPACITY IN GAL117 NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forbin uea oM1� <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑ 2. LEADED ❑ B. JET FUEL <br /> (Mme l implele PehPNpm Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NOWFUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑Be. OTHER <br /> ❑ 3.CHEMIGALPRODUCT <br /> ❑ 4. HAZARDOUSWASTE(hlHutlea COMMON NAME(M1om HazaNpua MataneY nnusnbrypaps) CASs Pmm Hualloi MehMM lnwMwypape) <br /> Ueatl 00) <br /> 0 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (CM oro item omyj ❑ 2. DOUBLEWALL EXTERIOR MEMBRANE LINER El 95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑BB OTHER <br /> TANK MATERIAL pw.n RIM 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> fCheFk orp item Dory) ❑ 2. STAINLESS STEEL ❑4. STEELCLADWIFIBERGLASS ❑ 8. FRP COMPATIBLE WI1W%METHANOL ❑9B. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-e4caNary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑N UNKNOWN <br /> (Check ons Rem DMH ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ B. FRP NON-CORRODIBLE JACKET ❑S9. OTHER <br /> REINFORCED PLASTIC(FRP) 1110. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING M. UNKNOW1,1433 DATE INSTALLED <br /> OR COATING <br /> CMck am demo ❑ 2'ALKYD UNING ❑ 4. PHENOLIC LINING ❑ e. UNUNED [IN OTHER ) <br /> OTHER CORROSION ❑ 1, MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNgM4 434 DATE INSTALLED <br /> PROTECTIONTION IFIF APPLICABLE <br /> LICABLE PROTECTION <br /> ❑ A. IMPRESSED CURRENT N. OTHER <br /> (Check onadw^onryl ❑ 2. SACRIFICIALANODE I (FwkW uae orYy) <br /> SPILLANDOVERFlLL YEAR INSTALLED TYPE(Fwloila 0*) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (ChxAYMeI aPPry) ❑ 1. SPIMCONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILLTUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> TANK LEAK DETECTION . <br /> IFSINGLEWALLTANK MPk"9 IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSEDPORTIONONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) Cl S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCIUATION(SIR) ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING 0 OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> pePone ❑Yea ❑No <br /> l <br /> Al <br /> CIIPAFORM(4/99) - FormeNy SWRCB Fom B <br />