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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> -a+ /--- (twa pages Per tank) <br /> P.Q. _ o/ <br /> TYPE OF ACTION 13 1.NEW SITE PERMIT ❑ t. AMENDED PERMIT �5. CHANGE OF INFORMATION) 0 6. TEMPORARY SITE CLOSURE <br /> (CAaak ons dem omy) ❑ T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (SppM,mean-brbuluu amy) (Spxiyclrorpe-Nrkcaluu orVyJ ❑ S. TANK REMOVED tW <br /> BUSINESS NAME(Sams u FACILITY NAME w DBA-Dokp BWMeu Aa) FACILITY IDB • t <br /> of <br /> LOCA oNw1TIliNSITE(0 <br /> 5 1.TANK DESCRIPTION <br /> TANK IDM TANK MANUFACTURE <br /> COMPARTMENTALIZED TANK ❑ Yae Na <br /> If-Yee.compl6M ona page tw aaN 1. <br /> DATE INSTALLLEDD(EA(YEAARNO)) TANK CAPACITY IN GAUONNS NUMBER OF COMPARTMENTS <br /> all v <br /> AGUTIONALDESCRIPTION(Flr .onW <br /> II.TANK CONTENTS <br /> TANK USE 132 PETROLEUM TYPE <br /> MOTOR VEHICLE FUEL 0/a. REGULAR UNLEADED JAZ. LEADED 0 S. JET FUEL <br /> P/ tkad,mmpero Patmlaum Type) 0l. PREMIUM UNLEADED //❑ 9. DIESEL 0 6. AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 01.. MIDGRADEUNLEADED ❑ <. WSOHDL 00, OTHER <br /> 0 3.CHEMICAL PRODUCT <br /> 0 4. HAZARDOUS WASTE(IwJudaa COMMON NAME(M1 Hazanlous Mah,"s Inwnhny ge) CAS It(hom NazaN,nt MatedaN Inwntorype9e) <br /> Used Oil) <br /> 17195 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK SINGLE WALL ❑ 3. SINGLE WALL VATH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Gluatraro dem onryJ ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 4. SINGLE WALL IN A VAULT 0 99 OTHER <br /> TANK MATERIAL-p Unary lank X,. SARE STEEL 0 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (CMckam dem ony) <br /> 02 STAINLESS STEEL 0 4. STEEL CLAD WIFIBERGLASS ❑ 6. FRP COMPATIBLE W/1W%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANKMATERIAL-eamn Mnk X- 1 CARE STEEL 0 3. FIBERGLASS/PLASTIC 0 8. FRPOOMPATIBLEW/1W%METHANOL ❑95. UNKNOWN <br /> (CM km ffinn. y) 0 2, STAINLESS STEEL 0 t. STEEL CLAD WIFIBERGLASS 09 FRP NON-CORRODIBLE JACKET 094 OTHER <br /> REINFORCED PIASTC(FRP) 010. COATED STEEL <br /> 0 S. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED 0 3. EPDXYLINING ❑ 5. GLASS LINING 095. UNMONM433 DATEINSTALLED <br /> OR COATING <br /> ❑ Z. ALKYD LINING ❑ t. PHENOLIC LINING >4. UNLINED 0B9. OTHER Forkxal usa <br /> on Item o ) <br /> OTHER CORROSION 0 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 431 DATE INSTALLED <br /> PROTECTIONIFAPPLICABLE PROTECTION A�� - <br /> ❑ 6. IMPRESSED CURRENT 89. OTHERS/-{JOS (Fwlocal uas oMy) <br /> (CMck orM dem any) ❑ 2. SACRIFICIAL ANODE 1a1/'L/✓ <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(Forbcaluu oMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> IcJ al m.t pp) 0 1. SPILL CONTAINMENT 0 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE 0 2. BALL FLOAT 0 t. EXEMPT <br /> 0 3, STRIKER PLATE <br /> W. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK CMak all that a IF DOUBLE WALL TANK OR TANK WITH BLADDER Cork aM dem o <br /> IdWl <br /> 01, VISUAL(E)[POSEDPORTION ONLY) 0 S. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 6. VADOSE ZONE 0 2. CONTINUOUSINTERSTTIALMONITORING <br /> 0 3. CONTINUOUS ATG 0 T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> 04, STATISTICAL INVENTORY RECONCILIATION(SIR). 6. TANKTESTING <br /> BIENNIAL TANK TESTING OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATELASTUSE �IOIW ESTIMATED QUANTITY OF SUBSTANC INING t35 TANK FILLED WITH INERT MATERIAL? <br /> 11ana <br /> MAR 2 9 2001 <br /> FNIVIRONMENT HEAR �'` <br /> CUPAFORM(4/99) �.. 'ERMlT/SERVICES Formerry SWRCB Forma <br /> � <br />