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UNIFIED PROGRAM C ONSOLIDA TED FORM <br /> SIZ ��a3 S <br /> UNDERGROUND STORAGE TANKS -TANK PAGE TANK <br /> (Mo pains PNtank) <br /> Pape of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ /. AMENDED PERMIT D 5. CHANGE OF INFORMATION) 0 5. TEMPORARY SITE CLOSURE <br /> (Glick ans item only) D T. PERMANENTLY CLOSED ON SIT- <br /> 0 3 <br /> IT-DJ RENEWAL PERMIT (sgfilymeaon-01-1-Y) ($PrcH,0A,.-lorlocalaaewIy) ❑ 6, TANKREMOVED 00 T <br /> BUSINESS NAME S. FACILITY NAME ar DBA.Oabp Ou,inus A,) FACILITY 10 ' I <br /> vF /op <br /> �, <br /> LOCATION WTHIN SITE(Op 6'onal) /]t <br /> Hoo57L,q v <br /> I.TANK DESCRIPTION <br /> TANK 10• O TANK MANUFACTURE ������� COMPARTMENTALIZED TANK •s ❑ No <br /> r /'r-a)W � rN�� IIYei,iamplale o.......or eacJl<unFa.menl. <br /> DATEINSTALLEO(YEARMO) 1 / TANK CAPACITY IN GADO/INS NUMBER OF COMPARTMENTS <br /> � �yF-s o o v 3 <br /> ADDITI NAL DESCRIPTION(Fprkasl var only) // ��^j�^ <br /> F L II.TANKCONTENTS <br /> U/ L <br /> y / TANK USE /32 PETROLEUM TYPE <br /> L(J/T MOTOR VEHICLE FUEL D 1a EGULaR UNLEAOED ❑ _, LEADED ❑ 5 JET FUEL <br /> (Il markw.mmpNae Rlmlrvm TyPel REMNM UNLEADED 0 J. DIESEL Cl 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM 0 is MIDGRADE UNLEADED D /. GASOHOL D99. OTHER <br /> Cl ]. CHEMICAL PRODUCT COMMON NAME prom HaaaNaus Matelots I-hhaYpayaJ CAS a prom Hasanktus Mafenab lnwnmry pre) <br /> ❑ /. HAZARDOUS WASTE(Inclwe, O�N Q D <br /> U,w 00 -r <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK D I INGLE WALL ❑ ]. SINGLE WALL WITH D 5. SINGLE WALL W1T,H INTERNAL BIADOER SYSTEM <br /> EXTERIOR MEMBRANE LINER D 95. UNKNOWN <br /> (Cnack one dam onry) . DOUBLE WALL Cl /, SINGLE WALL IN A VAULT <br /> [199 OTHER <br /> TANK MATERIAL-pnmary tank 0t. RE STEEL Cl ]. FIBERGLASS I PLASTIC 0 5. CONCRETE 095_ UNKNOWN <br /> (Cnack one tlem enryl 2. STAINLESS STEEL D/ REHFL CLAD IFIBERGIFRP D6 FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> TANK MATERIAL-,rTanaant lank D I BARE STEEL D 0. FI ERGLASS/PUSTIC 0 6. FRP COMPATIBLE WIWO%METHANOL D95W <br /> . UNKNON <br /> (Cnack ens rtem onry) 0 2. STAINLESS STEEL /. STEEL CLAD WIFISERGUSS 0 9. FRP NON-CONROOIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) D 10 MATEO STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING D (, RUBBER LINED ❑ ]. EPDXY LINING C35. CLASS LINING 95. UNKNOWNUJ GATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ /. PHENOLIC LINING Cl B UNLINED ❑99. OTHER (Forloc tans o ) <br /> Chack onr item on ) DATEINSTALLED <br /> OTHER CORROSION MANUFACTURED CATHODIC 0 J. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN /]/ Q 9 <br /> PROTECTION IF APPUCABLE PROTECTION <br /> ❑ /. IMPRESSED CURRENT [j 99 OTHER (Far Rc ua onry <br /> (Cnack onr item cAM 0 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL O YEAR INSTALLED TYPE IFarlo .....V) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CA•ck ad that optyl 1, SPILL CONTAINMENT 1. ALARM - ] FILL TUBE SHUT OFF VALV-� <br /> 0�111,. ,ROP TUBE D 2. BALL FLOAT_ 0 a, EXEMPT <br /> / <br /> W+ STRIKER PLATE <br /> _ IV.TANK LEAK DETECTION <br /> IFDOUBLE WALL TANK OR TANK WITH BLADOER'Geak ans arm"'Y) <br /> IF SINGLE WALL TANK(Chack all that• l <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) ❑ 27CON1. AL(BINGLE INTALL ERSTITIAL <br /> MONITOLT R/ <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE Ild�2. CONTINUOVSIMERSTITIAL MONITORING <br /> Cl J, CONTINUOVSATG ❑ T. GROUNDWATER ❑ ]. MANUAL MONITORING <br /> 04, STATISTICAL INVENTORY REMNOILIAT108(SIR)a D a. TANK TESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRMCIDAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 9allana D Y D N <br /> FomUITV SWRCB Farm <br /> CUPAFORM(4/99) , <br />