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UNIFIED PROGRAM CONSOLIDATED FORM <br /> � TA <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 1 �\ 0 <br /> (two pa ) <br /> P.9•_of_ <br /> TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT El5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (om*.kamly) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWALPERMIT (SP-11y r«o-for b«lu«my) (Spnify rn.m-fm bnl..mly) 8 TANK REMOVED <br /> ao <br /> BUSINESS NAME(u...FAcam «DBA-0..a 11®..A•) FACILITY ID: 1 <br /> R� 433 3 H <br /> LOCAnON WITHIN SITE(op6 .i) u1 <br /> L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shal I be submi to the local agency.) <br /> TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK es No 434 <br /> OVS O 1 X{KXl S vYi^.maw.m<p.a.6,r im ma.r..�ml. <br /> DATE INS ED(TEILRMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 2 <br /> ADDITIONAL DES N(Fm bale.o.y) 439 <br /> II.TANK CONTENTS <br /> TA14K USE 134 PC,ROLEUV TY E 7"2 <br /> 1. MOTOR VEHICLE FUEL REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL <br /> Ih. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑I . MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER❑3. CHEMICAL PRODUCT MMONNAME(6m wnrdom M.ai•hb4m.ryp•ae) 441 CAS#(6em wnrdm•Mnerul.Ivvmr«y p.ae) <br /> ❑4. HAZARDOUS WASTE <br /> (I W.u• oil) <br /> ❑95.UNKNOWN <br /> M. TANK CONSTRUCTION <br /> TYPE OF TANK 01. SINGLE WALL 03. SINGLE WALL WITH .. ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> ICkak me ke.mly7 EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> DOUBLE WALL ❑4. SIGNLE WALL M VAULT ❑99. OTHER <br /> TANK MATERIAL-pmu•p 1. BARE STEEL FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN w4 <br /> (Ck«k mc k..my) ❑2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL- u.e.ry unk0 1. BARESTEEL FIBERGLASS/PLASTIC 5. CONCRETE 0 95. UNKNOWN u5 <br /> (aaA...am my) ❑2. STAINLESS STEEL 4, STEEL CLAD WNIBERGLASS ❑8. FRP COMPTIBLE W/LOOK METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑5. CONCRETE <br /> TANK INTERIOR LINING 0 I.RUBBER LINED D 3.EPDXY LINING 5.GLASS LINING 0 95.UNKNOWN 444 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LININGfNLINED ❑99 OTHER <br /> (fh«t m.Kan mly) (For bul u.mlyl <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC 0 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44a DATE INSTALLED i9 <br /> PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT 09 OTHER <br /> (Cb.Y me Yanmly) ❑2 SACRIFICIAL ANODE (Forbin u•c mly) <br /> SPILL AND OVERFILL YEARINSTALLED 450 TY-PE(b, w.m1y) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 453 <br /> (C9.Ihwwy) 5k5,�,I SPILL CONTAINMENT J41199I ALARM ❑3 FILL TUBE SHUTOFF VALVE <br /> k 2 DROP TUBE 59'1 !J//���� BALL FLOAT ❑4 EXEMPT <br /> }�3 STRIKER PLATE / <br /> IV.TANK LEAK DETECTION(A d« ....fm..•nkmv9 pr.9r•.A.n w m6.kle4 a 0.bul.9ency.) <br /> IF SINGLE WALL TANK(Ce k.nwuppyl 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (Q«k...k4«m10 <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG ❑1 VISUAL(SINGLE WALL M VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DAT LA T USED(YR/MO/DAY FSTIMATF�QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> �a Qy tJ gallons C]Yes ❑ No <br /> UPCF(12/99 revised) l0 Formerly SWRCB Form B <br />