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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (hw pages per tang Page _ or _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE (CM1eck ane item only) '-M ]. PERMANENTLY CLOSED ON SITE o 03.RENEWAL PERMIT (Spenly reason-brbcelum orxy) (Spealymage-ta"aaalaeeonll9 0 B. TANK REMOVED 430 1 1 BUSINESS NAME(Same as FACILITY NAME a DBA.Doln9 BJsJmss Aa) FACILITY ID N LOCATION WITHI SITE(Oplloneo 431 ILLI i'o L OC.Y-it- R6, I.TANK DESCRIPTION TANK IDN TANK MANUFACTURER COMPARTMENDTANK 1:1 Yes 0 No 5D�3 unf lr,, It'Yes',complete Dna page breach mmpartmenl DATE INSTALLED(YEARRAO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS uNk. 20 3 Dib ADDITIONAL DESCRIPTION(Forbcel use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL ❑ 1.MOTOR VEHICLE FUEL 0 1a. REGULAR UNLEADED ❑ 2. LEADED B. AVIATION FUEL (Ir maAaE,corapam ibhoksm Type) [03 lb PREMIUM UNLEADED ❑ 3. DIESEL 2. NON-FUELPETROLEUM 010. MIDGRADE UNLEADED ❑ 4. GASOHOL 98. OTHER NZAfi Nby(� 0 3.CHEMICAL PRODUCT COMMON NAME(hom HezaMous MaMnela Invenforypa9e) CAS N(M1om Hezenloua Materials Inrenforypege) 0 4. HAZARDOUS WASTE(Iaasu s UI Oat 7195 LJNKNQM III.TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLEWALLWITH ❑ 5. SINGLE WALLW4TH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER 095. UNKNOWN (Check am dem any) 0 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 0 1 BARESTEEL ❑ 3. FIBERGLASS I PLASTIC 5. CONCRETE 095. UNKNOWN (Check one item only) 0 2. STAINLESS STEEL 04 RSTEEL Cl-AD EINFORCED PLASTICIBE (FRPS 0 8, FRP COMPATIBLE W1100%METHANOL 099. OTHER TANK MATERIAL-seconEary tank 0 1 BARE STEEL ❑ 3. FIBERGIASS/PLASTIC 0 8, FRP COMPATIBLE WI100%METHANOL 095. UNKNOWN (Check am item Dory) 0 2. STAINLESS STEEL ❑ 4 REINFORCED PLASTIC(FRP) 0 9. FRP NON-CORRODIBLE JACKET _ 099. OTHER [110 COATED STEEL ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING El5. GLASS LINING [I SO UNKNOWN433 OR COATING11KY \� 2.ALD LINING ❑ 4. PHENOLIC LINING ❑ e. UNLINED TL 99. OTHER NON Fa local use (CM1ackom Uemon DATE INSTALLED OTHER CORROSION 1, MANUFACTURED CATHODIC ❑ 3. FIBER GLASS REINFORCED PLASTIC ❑95. UNKNOWN 494 PROTECTION IF APPLICABLE PROTECTION �-r 99. OTHER N ONC ❑ 4. IMPRESSED CURRENT C-r (Forlocal use only) (Check am item only) 0 2. SACRIFICIALANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlacal use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all that apply) 0 1 SPILL CONTAINMENT 0 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE ❑ 2. BALLFLOAT 0 4. EXEMPT ❑ 3. STRIKER PLATE IV.TANK LEAK DETECTION. IF SINGLE WALL TANK(Chick all theta ). IF DOUBLE WALL TANK OR TANKWITH BLADDER(CmcA one item only). ❑ 1, VISUAL(EXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) 0 e. VADOSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG 0 ]. GROUNDWATER 0 3. MANUAL MONITORING C 4. STATISTICAL INVENTORY RECONCILIATION(SIR)( ❑ 8. TANKTESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMI I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YWMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL] Ballon. 0 Yea ❑No Formerly SWRCB Form 8 CUPAFORM(4199)