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UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (Mo pages per lank) <br /> Page _ or _ <br /> ❑ 5. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4 AMENDED PERMIT 5. CHANGE OF INFORMATION) 0 T PERMANENTLY CLOSED ON SITE/ <br /> (Check orla item BnM t <br /> ❑3.RENEWAL PERMIT (SpsclH maaPn-IorbcN uaaoM'/ (SperYyFMrps brloul uss oMy) ❑ S.TANKREMOVED 430 J <br /> BUSINESS NAME(Same ea FACILITY NAME aDBA-OORIg Bus'vrees Aa) FACILITY ID/ <br /> LOCATION NATXIN SITE(UPep.0 431 A �a J-66 <br /> 3 3 ur h <br /> I.TANK DESCRIPTION <br /> EAMnOML <br /> IDS , TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Vaa No <br /> 'I __ Q� 'yra%complete one page for eaM computmenc <br /> LED(YEARdO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> i� �v D <br /> DESCRIPTION(Forbcal use-W <br /> II.TANK CONTENTS <br /> TANKUSE 412 PETROLEUM TYPE <br /> H 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED X'2. LEADED ❑ 5. JET FUEL <br /> (rymarMN.comSense F_"Aaa` Trys) tb. PREMIUM UNLEADED ❑ 9. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c. MIOGitADE UNLEADED ❑ 4. GASOHOL ❑eB. OTHER <br /> ❑ 3. CHEMICALPRODUCT COMMON NAME(hom Hazardous Makm+la anarROrypege/ GS/(hom Hsonase Materials lnwmwypaga) <br /> ❑4.HAZARDOUS WASTE yrlNudea <br /> UseC GiO <br /> 111.TANK CONSTRUCTION <br /> TYPEOFTANK 1. SINGLE WALL ❑ 3. SINGLE WALL WTH ❑ 5. SINGLE WALL WITH INTERNAL BI-ADDER SYSTEM <br /> (CMOk."re.rW ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT 0 N. OTHER <br /> TANK MATERIAL-pNnerY Mnk1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑B5. UNKNOWN <br /> (Check.Mm aR19 ❑ 2. STAINLESS STEEL 04. STEEL CLADWFIBERGUSS ❑ B. FRP COMPATIBLE W/10(3%METHANOL 13. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL aacond qYM 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL [0 <br /> �yR9955�. UNKNOWN <br /> (Check one item arO9 ❑ 2. STAINLESS STEEL ❑ L STEEL CLAD WIFISERGLASS ❑ 9. FRP NON-00HRODIBLE JACKET P.r.- OTHER N�TLJ <br /> REINFORCED PLASTIC(FRP) 10. COATED STEEL <br /> ❑ S. CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING 0 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNIWOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNUNED 089. OTHER (�'kxadusssanw <br /> (CMckons Rano DATE INSTALLED <br /> OTHER CORROSION ❑ t. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ <. IMPRESSED CURRENT �-09. OTHER (Fmbcoluss oMy) <br /> (Chackaheftwe ) ❑ 2. SACRIFICIALANODE <br /> SPILLANOOVERFILL YEAR INSTALLED TYPE(ForMoalus Ann OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED AVIA <br /> (Check N that appy) 0 1. SPILLCONTAINMENT ❑ 1. ALARM 0 3, FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4 EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> 'IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check aN bal aEeW IF DOUBLE WALL TANK OR TANK WITH BLADDER(Cheek one Rem Only): <br /> ❑ 1, VISUAL("POSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE ❑ Z CONTINUOUS INTERSTITIAL MONITORING ' <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING IS, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST UUSSE'DCYRMO/DAY) '7 ESTIMATED QUANTITY OFSUBSTANCEREMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 17 / OLS I Y / BaYons ❑Y... kN. <br /> CUPAFORM(4199) ` Formerly SWRCB Farm B <br />