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0 Mw <br /> A& <br /> U N IF IED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (hvo pages per tank) <br /> Page _ of <br /> TYPE OF ACTION O L NEW SITE PERMIT D 4. AMENDED PERMIT 0 5. CHANGE OF INFORMATION) 0 B. TEMPORARY SITE CLOSURE <br /> (ChecForle Nemony) \�0 T. PERMANENTLY CLOSED ON SITE p <br /> 03.RENEWAL PERMIT (Sperllynason-forloosl."ary) (Sped/,drenpe-lorlacal use only) L'J B. TANK REMOVED 430 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doirp Business Aa) FACILITY 10# 1 <br /> CppPEEIFt>2D LLL_ O a 4 0 5 4 <br /> LOCATION WITHIN SITE(Opaona9 431 <br /> 124�o t1x..kE (ta <br /> I.TANK DESCRIPTION <br /> TANKID# TANKMANUFAOTURER COMPARTMENTALIZED TANK 0 Yea D No <br /> 23�a$ol V NIf'Yes%complete one Page for each compartment. <br /> DATE INSTALLED(YEARI TANK CAPACITY IN GALLONS NUMBER OFCOMPARTMENTS <br /> uNk. Is <br /> ADDITIONAL DESCRIPTION(Forloosl uas only) <br /> IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1, MOTOR VEHICLE FUEL 0 ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (Ifmarke0,complete Petroleum Type) D ID. PREMIUM UNLEADED D 3. DIESEL 0 8. AVIATION FUEL <br /> ❑ 2. NON-FUELPETROLEUM ❑1c MIDGRADE UNLEADED 0 4. GASOHOL N. OTHER UNI'.• <br /> ❑ 3. CHEMICALPRODUCT <br /> ❑ 4. HAZARDOUS WASTE pnoVoes COMMON NAME(ham Hazamfoos Mate#alslmentorypage) CAB#(hom HazaxI us Materials InwntoryJege) <br /> uead Ong <br /> El 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL 0 3. SINGLEWALLWTH ❑ 5. SINGLE WALL WTH INTERNAL BUDDER SYSTEM <br /> (Check one dem any) ❑ 2. DOUBLEWALL EXTERIOR MEMBRANE LINER D95. UNKNOWN <br /> 0 4, SINGLE WALL IN A VAULT D 99 OTHER <br /> TANK MATERIAL-pnmary tank 1 BARE STEEL 0 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE Des. UNKNOWN <br /> (Checkonel(emonly) ❑ 2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑ B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank D 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC 0 8. FRPCOMPATIBLEW/100%METHANOL ❑95. UNKNOWN <br /> (Check one dem orI D 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS 09, FRP NON-CORRODIBLE JACKET D99. OTHER <br /> REINFORCED PLASTIC(FRP) 1110 COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING D 1. RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS UNING B5. UNKNOWNd33 DATE INSTALLED <br /> OR COATING <br /> 0 2. ALKYDUNING ❑ 4. PHENOLIC LINING 0 8. UNLINED 0W. OTHER <br /> (Check am demon (Forlacal use a <br /> OTHER CORROSION 0 1, MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 1199, OTHER <br /> (Check ore dem mW D 2. SACRIFICIAL ANODE I (Forlcczl use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forl000l use"W OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (CheckaeflMfepply) D t SPILL CONTAINMENT ❑ 1. ALARM D 3. FILL TUBE SHUT OFF VALVE_ <br /> D 2. DROPTUBE ❑ 2, BALL FLOAT D d. EXEMPT <br /> D 3. STRIKER PLATE <br /> fIV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANKCheak As thata IF DOUBLE WALL TANK OR TANK WITH BLADDE0. Check one item onl : <br /> 0 1, VISUAL(EXPOSED PORTION ONLY) D 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATE) 0 8. VADOSE ZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 2. GROUNDWATER 0 3. MANUALMONITORING <br /> D 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ D B. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING _=11 <br /> 35 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Na <br /> ❑Vas <br /> CUPAFORM(4/99) 0 • Formerly SWRCB Form B <br />