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UNIFIED PROGRAM CONSOLIDATED FORM P r ,/ <br /> A„(/TANKS <br /> UNDERGROUND STORAGE TANKSTANKPAG l <br /> (Mro Pages per fank) <br /> �-s 1( Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT Idl 5. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> (Check..4.M.W /// """ ❑ T. PERMANENTLY CLOSED ON SITE <br /> 113.RENEWAL PERMIT (Specirynason-f.rhvaluee.nty) (Spetlly gronpa-brtaulum only) - ❑ B.TANKREMOVED 430 <br /> BUSINESS NAME(Same ee FACILITY NAME.,DBA-WIN Business Aa) 1 FACILITY IDN 1 <br /> L TION Irof N IT (Opfiona� 431 L !Zb ' ,^ O I.TANK DESCRIPTION <br /> TANKIDY TANKMANUFACTURER COMPARTMENTALIZED TANK ❑ Yee ❑ No <br /> OIYYei,complete one page for each compartment <br /> DATE INSTALLED(YEARH40) Lri/ ( L TANKCAPACITY INGALLONS s� NUMBER OF COMPARTMENTS <br /> u <br /> ADDITIONAL DESCRIPTION(Forbcalu».My) Vv tc v\, It J )e/`' <br /> II.TANK'r/C01NTa(BNTTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ t.MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ❑ 2. LEADED ❑ 5.JET FUEL <br /> (Nmerke0,complete Petmle9m Type) ❑1h. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑10 MIOGRADE UNLEADED ❑ 4. GASOHOL ❑88. OTHER <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(aom Hazallous MaronaM tmenforypage) CASe(h.m Nezardous Maronalslownforypege) <br /> 11 4, HAZARDOUS WASTE(/ntl - <br /> USM Oi0 <br /> 1195 KNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLEWALL ❑ 3. SINGLEWALLWITH ❑ S. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLEWALL EXTERIOR MEMBRANE LINER ❑85. UNKNOWN <br /> ❑ 4.SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-ptlmary tank ❑ 1, BARE STEEL ❑ 3. FIBERGUSS/PLASTIC ❑ 5. CONCRETE El 95. UNKNOWN <br /> (Chock ore Hem Dory) ❑ 2. STAINLESS STEEL ❑4 STEEL CUD IFIERGLA S ❑ 8. FRP COMPATIBLE W1100%METHANOL 110. OTHER <br /> REINFORCED B <br /> TANK MATERIAL.secondary lank ❑ t BARE STEEL ❑ 3. FIBERGUSS/PLASTIC ❑ 9. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN <br /> (Ch ko.Hemonly) ❑ 2. STAINLESS STEEL ❑ 4.RENFORCEDPLABERTIC FRP) ❑ 9_ FRP NON-CORRODIBLE JACKET ❑B9. OTHER <br /> ❑10. COATED STEEL <br /> ❑ S.CONCRETE <br /> TANK INTERIOR LININGDATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS LINING 085. UNKNOWN433 <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER F.rlocal...n <br /> (Checkoetfrompn ) DATEINSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PUSTIC 095. UNKNOWN 434 <br /> PROTECTION IF APPUCASUE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER (F.rlowl...nly) <br /> (Check one item only) ❑ 2. SACRIFICIALANODE. <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local pea oMy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chea0thatapply) ❑ 1. SPILL CONTAINMENT ❑ t ALARM _ ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION. <br /> IF SINGLE WALL TANK(C/ kag lh.t.R ) IF DOUBLE WALL TANK OR TANKWITH BLADDER Check.MHem. : <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATO) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUSINTERSTITIALMONITORING <br /> ❑ 3. CONTINUOUSATG. - ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4, STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRRAO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallon. - ❑Yes ❑No <br /> CUPAFORM(4/99) Forrnerly SWRCB Form B <br />