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J <br />• <br />-� UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />Page _ of _ <br />F ACTION U1. NEW SITE PERMIT 11 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) 11 6. TEMPORARY SITE CLOSURE <br />TYPE O <br />(Check F ACTIOe He. only) 113 <br />7. PERMANENTLY CLOSED ON SITE <br />❑3. RENEWAL te--1 mamn-/arlo use only) (Speony Muage-1 f=laseanly) D S. TANKREMOVED 430 <br />PERMIT <br />1 <br />BUSINESS NAME (Same as/�FACNTY NAME wDBA- Business As) 3 <br />FA:, l T IDt <br />``z�w,ef � O <br />mart <br />431 <br />431 <br />LOCATION WTHIN SUE (Op ima0 <br />I. TANK DESCRIPTION <br />432 TANK MANUFACTURER <br />��I <br />_ 433 COMPARTMENTALIZED TANK D Yes ,A No <br />434 <br />D%n r- <br />It'Yei, compete ane page tar ii d obeiPIMM-inNSTALLETANK <br />ACITYIN S <br />ETANK0eel�(F�1.1.wly) <br />436 NUMBER OFC MPARTMENT <br />C <br />4M <br />ONAL DE <br />II. TANK CONTENTS <br />MO <br />TANKUSE 439 <br />PETROLEUM TYPE <br />D REGULAR UNLEADED ❑ 2. LEADED <br />❑ 5. JET FUEL <br />MOTOR VEHICLE FUEL <br />m ,so. campleb Penoleum Type) <br />ta. <br />D Its. PREMIUM UNLEADED �R3. DIESEL <br />D S. AVIATION FUEL <br />D 2. NON-FUELPETROLEUM <br />11 tc MIDGRADE UNLEADED D 4. GASOHOL <br />[199. OTHER <br />D 3, CHEMICAL PRODUCT <br />441 <br />CAS tl (holo Hazartbus MabnNs Invenlay page) <br />442 <br />D 4. HAZARDOUS WASTE Onol les <br />COMMON NAME (from Hazamoas Mabnals Inkentary Page) <br />o,tesI:4 Fi44Sy7-G3`/6 <br />D95. UNUssKNOWN <br />III. TANK CONSTRUCTION <br />TYPE OF TANK Cl 1. SINGLE WALL D 3. SINGLEWALLWATH <br />❑ 5. SINGLE WALL WITH INTERNAL BIADDER SYSTEM <br />4413 <br />EXTERIOR MEMBRANE LINER <br />D95. UNKNOWN <br />(LhecY ons ilem only) DOUBLE WALL D 4 SINGLE WALL IN A VAULT <br />[199. OTHE0. <br />TANK MATERIAL -Primary tank 11 1 BARE STEEL 11 3, FIBERGLASS/PLASTIC <br />Cl 5. CONCRETE 1195. UNKNOWN <br />444 <br />lbm 02. STAINLESS STEEL STEELCLAD <br />❑ 6. FRPCOMPATIBIEW/100%METHANOL 1199. OTHER <br />(Check one oNy) ,0151. <br />WNIBERGLASS <br />REINFORCED PLASTIC FRP <br />TANK MATERIAL -semMaly lank D 1. BARE STEEL D 3. FIBERGLASS/PLASTIC <br />❑ 6. FRP COMPATIBLE W/WO%METHANOL 1195. UNKNOWN <br />445 <br />(Lhec*one item orgy) 11 2, STAINLESS STEEL STEEL CLAD WIFIBERGLASS <br />❑ 9. FRP NONOORRODIBLE JACKET 1199. OTHER <br />REINFORCED PLASTIC (FRP) <br />1110. COATED STEEL <br />05. CONCRETE <br />TANKINTERIORUNING Cl 1, RUBBER LINED 03. EPDXY LINING <br />05. GLASS LINING D95. UNKNOWN d48 DATE INSTALLED <br />447 <br />OR COATING <br />❑ 2. ALKYD LINING ❑ 4. PHENCUC LINING <br />❑ a. UNLINED cl 99. OTHER Farloaluse oM <br />Check one item only)DATE INSTALLED <br />OTHER CORROSION D 1. MANUFACTURED CATHODIC 03. FIBERGLASS REINFORCED PLASTIC [195. UNKNOWN d48 <br />449 <br />PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br />Cl N. OTHER (Fwlaoluu oNy) <br />(Cheat one item only) D 2. SACRIFICW.ANODE <br />SPILL AND OVERFILL YEAR INSTALLS 450 TYPE (Fazloaluse aNy) <br />451 �OVERFILLPROTECTON IPMpE�Ni_YEAR INSTALLED 452 <br />VALVE/_ <br />� SPILLCONTAINMENT � <br />61 -ALARM FILL_ i^a FILL TUBE SHUT OFF <br />(Check ad that appy) [�`L. <br />❑ Z. BALL FLOAT ❑ 4. EXEMPT <br />Cl 2. DROP TUBE <br />D 3. STRIKER Pwo <br />IV:: TANK LEAKDE'IECTION <br />. <br />- <br />45] IF DOUBLE WALL TANK OR TANK WITH BLAODER(Cneck m oinsin nly)' <br />454 <br />IF SINGLE WALL TANK(Check 00 bat appy): <br />❑ 1, VISUAL (EXPOSED PORTION ONLY) ❑ S. MANUALTANK GAUGING(MTG) <br />❑ 11. VISUAL(SINGLE WALLIN VAULT ONLY) <br />❑ 6. VACOSE ZONE <br />Zt Y. CONTINUOUS INTERSTITIAL MONITORING <br />D 2. AUTOMATIC TANK GAUGING(ATGI <br />D 3. MANUAL MONITORING <br />D 3. CONUNUOUSATG D 7. GROUNDWATER <br />D 4. STATSTICAL INVENTORY RECONCILIATION (SIR) ❑ 6. TANK TESTING <br />BIENNIALTANKTESTING D99. OTHER <br />V TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE:= <br />QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED HATH INERT MATERIAL] <br />57 <br />ESTIMATED DATE LAST USED (YRIMOIOAY) I55 ESTIMATED <br />gallons D Yes D No <br />Formerly SWRCB Form B <br />UPCF (1199) <br />