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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of_ TYPE OF ACTION 1.NEW PERMIT ❑ 4.AMENDED PERMIT 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (S'eifyreason) ❑ S.TANK REMOVED BUSINESS NAME(Same asFACILITY NAME or DBA-Doing Business As) 3, FACILITY IFI I. ujfNE Coo"??? STh7-/OM ?- S,9 (4 LOCATION WITHIN SITE(Optional) 431 1111 E. k 07-rLC_7 A4.1-A4 LMv E , L 0M ,r CA- - 9 S Z Li D L TANK DESCRIPTION (A scaled plot plan with the location of the UST system includingbuildings and landmarks shall be submitted to the local agency.) TANK ID# / 1 4 n 432. TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes E] No 434. TROSQ6 2S If"Yes;'wn,lete ane page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 437 1998 htj'-y l2 DDD swaCC ADDITIONAL DESCRIPTION(Foe local use only) 43g L)N Leh-0 II.TANK CONTENTS TANK USE 439- PETROLEUM TYPE 440 Y" 1. MOTOR VEHICLE FUEL %a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchael,4 to pinc Peooleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardoes Materials Inventory page) 441CAS#(fima Hazardous Mamdals Inventory page) 442. ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑F SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER LI 95. UNKNOWN . DOUBLE WALL [14. SINGLE WALL IN A VAULT [199. OTHER TANK MATERIAL-promrytank 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one nem only) [12. STAINLESS STEEL %4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 08. FRP COMPTIBLE W/100%METHANOL [_1 95,UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. PRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING Q5.GLASS LINING ❑95.UNKNOWN 446, DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING Mks.UNLINED [199.OTHER Check one item only) OTHER CORROSION 1.MANUFACTURED CATHODIC ❑3.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT [199.OTHER fA Iicable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILLYEARINSTALLED 450, TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL ON AINMENT 1.ALARM El3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE 2.BALL FLOAT [14.EXEMPT [13.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) [:16.VADOSE ZONE V2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG [17.GROUNDWATER ❑3.MANUAL MONITORING El 4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00