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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 ons item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Speeilyreason) (Specify rtason) ❑ S.TANK REMOVED BUSINESS NAME(Sasne as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY ID: I. LOINS eo0Nr2y STA-Tion1 }S9ti LOCATION WITHIN SITE(optional) 431, IIII 96TTL-4FA4A" LA-IVES LpAT CA - 4$ 240 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ❑ No 434. TAos o6 ?- 2-4 If"Yes,'cuns,lete one page for each compartment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAR/MO) 61000 Z 437. ADDITIONAL DESCRIPTION(For iocel use only) 438. II.TANK CONTENTS TANK USE 439. PETROLEUM TYPE 440. R( 1. MOTOR VEHICLE FUEL ❑1 a. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (Ifchscked,complete Petmisum Type) jKIb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haardow Materials lnventotypage) 441' CAS#(from Hazardous Materials Inventory page) 442, ❑ 4. HAZARDOUS WASTE (Includm Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [:13. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN [12. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 01. BARE STEEL Ll 3. FIBERGLASS/PLASTIC El 5. CONCRETE El 95.UNKNOWN 444. (Chock one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/100%METHANOL El 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED ❑99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC [13.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN "S. DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT ❑99.OTHER FA licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEARINSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEARINSTALLED 451. (Check all that apply) Ell.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ❑2.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.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) ❑6.VADOSE ZONE ❑2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING El 4. STATISTICAL INVENTORY RECONCILIATION El S.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 451' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456TANK FILLED WITH INERT MATERIAL? 451 gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 hltp://w".unidoes.org Rev.02/16/00