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441 UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT <br />(Check one kem oN), <br />113. RENEWAL Isadro reason -Lor local use omy) <br />TANKS <br />❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br />❑ 7. PERMANENTLY CLOSED ON SITE <br />(SpecAychdMJe-larla®I use.1y) ❑ 6. TANKREMOVED dao <br />PERMIT- <br />1 <br />BUSINESS NAME(Sameas FACIUTYNAME or DBA-Oc 9Business As) 3 FACIUTlIDi -' <br />s <br />%% <br />0/"' <br />oW r id <br />431 <br />LOCATION WITHIN SITE (Oph'ona8 <br />I. TANK DESCRIPTION <br />TANK TOY 432 TANK MANUFA TURER <br />433 COMPARTMENTALIZED TANK❑ Yas o <br />431 <br />'�// <br />It'Yepomplele one page for eaN compar9nenL <br />s' <br />V ` <br />DATE INSTAL D(Y 435 TANK TTY IN GALL NS <br />436 NUMBER OF COMPARTMENTS <br />437 <br />//1 <br />-{ $ 61ipo0 <br />436 <br />ADDITIONAL DESCRIPTION (Fwi.f use oNy) <br />II. TANK CONTENTS <br />TANK USE 439 <br />PETROLEUM TYPE <br />❑ 2. LEADED <br />❑ 5. JET FUEL <br />610 <br />1. MOTOR VEHICLE FUEL <br />(ItmarkeA. mmphle Pelmleum Type) <br />-,*Ja. REGULAR UNLEADED <br />❑ lb. PREMIUM UNLEADED ❑ 3. DIESEL <br />❑ 6. AVIATION FUEL <br />❑ 2. NONfUEL PETROLEUM <br />❑ 1c MIDGRADE UNLEADED ❑ 4. GASOHOL <br />(IN. OTHER <br />❑ 3. CHEMICALPROCUCT <br />COMMON NAME (hom Mazallous Malenals lnwnmrypage) <br />M1 <br />CASe(Imm Haxallous Mavmalslmmftmrypege) <br />442 <br />❑ d. US"HAZ00)0U5 WASTE (IMudes <br />095. KNOWN <br />III. TANK CONSTRUCTION <br />TYPE OF TANK ❑ 1 SINGLE WALL ❑ 3. SINGLE WALL WITH <br />❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br />443 <br />EXTERIOR MEMBRANE LINER <br />(Check one item only)re�f, DOUBLE WALL <br />095. UNKNOWN <br />❑ 4. SINGLE WALL IN A VAULT <br />[IN. OTHER <br />TANKMATERIAL-pnmaq=k ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC <br />❑ 5. CONCRETE 095. UNKNOWN <br />441 <br />(Checkane item ony) ❑ 2. STAINLESS STEEL 4. STEEL CLAD <br />)KIBERGLASS <br />❑ B. FRP COMPATIBLE Wl100%METHANOL N. OTHER <br />REINFORCED PLASTIC FRP <br />TANKMATERIAL-seruiWeTtenk❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC <br />❑ 8. FRP COMPATIBLE W IW%METHANOL ❑95. UNKNOWN <br />415 <br />(Check one item only) ❑ 2. STAINLESS STEEL Q�4. STEEL CLAD WMBERGLASS <br />❑ S. FRP NONCORROOIBLE JACKET 099. OTHER <br />REINFORCED PLSTIC(FRP) <br />❑ 10. COATED STEEL <br />❑ 5. CONCRETE <br />TANK INTERIOR LININGDATEINSTALLED <br />❑ 1. RUBBER LINED ❑ 1. EPDXY LINING <br />❑ S. G1A55 LINING ❑ 95. UNKNOWN NB <br />M7 <br />OR COATING <br />❑ 2. ALKYD UNING ❑ 4. PHENOLIC LINING <br />❑ 6. UNUNED ON. OTHER Forloalu.,mf <br />Check one item pM <br />DATE INSTALLED <br />[:195. UNKNOWN 448 <br />449 <br />OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC <br />PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br />099. OTHER (Forlocal use only) <br />(Chet cm,femonly) ❑ 2. SACRIFICIALANODE <br />d51 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED <br />452 <br />SPILLANO OVERFILL YEAR INSTALLED 450 TYPE (Forloml useonly) <br />/�JY Il� <br />113. FILL TUBE SHUT OFF VALVE ! <br />(Check all that apply) SPILLCONTAINMENT Mg <br />�-1. ALARM +=F-1-$ <br />❑ 2. BALL FLOAT ❑ C EXEMPT <br />❑ 2. CROP TUBE <br />❑ 3. STRIKER P - <br />f IV:. TANK'. LEAK DETECTION <br />453 IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check ora nem only): <br />461 <br />IF SINGLE WALL TANK (Check all Mat apply): <br />❑ 1, MSUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) <br />❑ 1. VISUAL (SINGLE WALLIN VAULT ONLY) <br />❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 8. VADOSE ZONE <br />. CONTINUOUS INTERSTITIAL MONITORING <br />❑ 3. CONRNUOUSATG ❑ 7. GROUNDWATER <br />❑ 3. MANUAL MONITORING <br />❑ 4. STATISTICAL INVENTORY RECONCIUATION(SIR)8. TANKTESTING <br />BIENNIALTANKTESTING ❑99. OTHER <br />V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE'" <br />ESTIMATED DATE LAST USED (YRIMOIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 458 TANK FILLED WITH INERT MATERIAL? <br />457 <br />gaiws ❑ Yea ❑ Nh <br />UPCF (1/99) <br />Formerly SWRCB form B <br />