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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (haro pages Isar tank) <br /> Papa _ of <br /> TYPE OF ACTION D 1,NEW SITE PERMIT D 4. AMENDED PERMIT Cl 5, CHANGE OF INFORMATION) D 5. TEMPORARY SITE CLOSURE <br /> fCAeok plla dem onry9 ❑ T PERMANENTLYCLOSED ON SITE <br /> D 3,RENEWAL PERMIT (SpxNynaspn-/orMwlva aHyl (Spa.y CMrps-AsrbW uw only) eir. TANKREMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME w DBAADing Busklea As) FACILITY ID# 1 <br /> L TqN WITHIN SITEPdo^a9 s <br /> 1.TANK DESCRIPTION <br /> TANK ID/ TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ yes No <br /> „^ II'Yes',mmplNs we <br /> pope fw eam mmpWnenf. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL OE ON(Fo/ vss Brow <br /> N.TANK CONTENTS <br /> TANK BE 432 PETROLEUM TYPE <br /> j.�t. MOTOR VEHICLE FUELa. REGULAR UNLEADED 2. LEADED ❑ 5. JET FUEL <br /> Oma al..plate WfmMum Typ) DIE. PREMIUM UNLEADED ❑ 3. DIESEL Cl 8. AVIATION FUEL <br /> D 2. NON-FUELPETROUEUM D1c MIDGRADE UNLEADED D C GASOHOL 099. OTHER <br /> D 3. CHEWCALPRODUCT COMM NAME pmm Haxagous AWNnals lokemory Page) CAS 9(/mm HersNcvs Malenala lnwWWMe) <br /> D 4. HAURDOUS WASTE(IMoeea <br /> Us"04 <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL D 3. SINGLE WALL WITH D 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Cook one dem only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT D 99. OTHER <br /> TANK MATERIAL-primary lank 1 BARE STEEL Cl 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> fcl karia dem ordy) ❑ 2 STAINLESS STEEL D 4. STEEL CLAD WIFIBERGUSS D B. FRP COMPATIBLE Wil M%METHANOL 099. OTHER <br /> REINFORCEDPLASTIC FRP) <br /> TANK MATERIAL-sem darytank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 9. FRP COMPATIBLE WflW%METHANOL 1195. UNKNOWN <br /> (Check..Aemonly) ❑ 2. STAINLESS STEEL D 4. STEEL CUD WIFIBERGUSS Cl 9. FRP NON CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) D 10. COATED STEEL <br /> D 5.CONCRETE <br /> TANK INTERIOR LINING 1 RUBBER LINED D 3. EPDXY LINING D 5. GLASS LINING D 95. UNKNOVM433 DATE INSTALLED <br /> ORCOATING <br /> Cl 2. ALKYD LINING ❑ 6. PHENOLIC LINING UNLINED El N. OTHER Fwbcal use ) <br /> (CAxk ons demo ) <br /> OTHER CORROSION 1 MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 DATE INSTALLED <br /> D <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ d. IMPRESSED CURRENT ❑99. OTHER (Forlacal use oMyJ <br /> (QhBLk od ilem oMy) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forbcal use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check ab that apply) Cl 1 SPILL CONTAINMENT D 1. ALARM 3. FILL TUBE SHUT OFF VALVE <br /> D 2 DROP TUBE D 2 BALL FLOAT_ D 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> .TV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check ed that apply): IF DOUBLE WALL TANK OR TANK WITH BUDDER(Cl k one dem on ): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> D 2. AUTOMATIC TANK GAUGING(ATG) ❑ 5. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> D 3. CONTINUOUSATG D T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> D 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ B TANKTESTING <br /> BIENNIAL TANK TESTING - 99, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRMIOIDAyy%.. / ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WTH RT MATERIAL? <br /> aF ( O gallons Yes ON. <br /> CUPAFORM(4/99) �/ k� Fofinedy SWRCB FOd <br />