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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> 05/55-73 (1VOPa9espe1tank) <br /> Page _ o1 _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT Cl 4.AMENDED PERMIT �5. CHANGE OF INFORMATION) 0 e. TEMPORARY SITE CLOSURE <br /> (Check ana dem only) <br /> ❑3.RENEWAL PERMIT0 T. PERMANENTLY CLOSED ON SITE <br /> (Specilymason-brloml use onM (Spec Ay Charge-brlxel use oMy) 0 B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doin mine`s As) FACILITY IDB o <br /> LOCATION IMTHIN SITE(Ophonsto 431 <br /> I.TANK DESCRIPTION ' <br /> TANK IDd TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea Xv. <br /> (iI(/{'f,/FOL 1/Yea',mmple(e ons page br earn m parMant. <br /> DATEINSTALLED(YEAWO) TAN CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> L(� <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 0 2. LEADED 0 5. JET FUEL <br /> (it marked,complete Raholaum Type) 01b. PREMIUM UNLEADED 0 3, DIESEL 0 6 AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 0 tc MIOGRADEUNLEADED 0 4. GASOHOL 099. OTHER <br /> 0 3. CHEMICAL PRODUCT <br /> 04. HAZARDOUS WASTE(IrMuches COMMON NAME(hom Hazardous Marshes,lnwnbrypage) CAS M(Bom Hezudour Metetlals lnwnforypa9e) <br /> Usad Oil) <br /> 0 95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALL WTH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 4, SINGLE WALL IN A VAULT 0 99, OTHER <br /> TANK MATERIAL-primary lank >r-1 BARE STEEL 0 3. FIBERGLASS I PLASTIC 0 5. CONCRETE 095. UNKNOWN <br /> (Chackomlbmonry) ❑ 2. STAINLESS STEEL 0 4, STEEL CUD WTISERGUSS 0 8. FRP COMPATIBLE WM00%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank N BARE STEEL Cl 3. FIBERGLASS/PLASTIC 0 8, FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEELCUDWNISERGLASS 0 9, FRP NON-CORRODIBLE JACKET /p� �099. OrywwwwTHE�R� <br /> REINFORCED PUSTIC(FRP) 010, COATED STEEL /V 0 <br /> 5. /v <br /> ❑ CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 05 GLASS LINING 095. UNKNOM433 DATEINSTALLED <br /> OR COATING11 `� <br /> Checkoneltemon ) 2.ALKYD LINING ❑ e. PHENOLIC LINING �L,I 8. UNLINED ❑99. OTHER <br /> ' v (Forloca)use onto <br /> OTHER CORROSION 1, MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN' am DATE INSTALLED <br /> ?heck ons CTION IF <br /> PROTECTION 11 <br /> (Check arta irom only) ❑ 2. SACRIFICIALANODE 4. IMPRESSED CURRENT ❑99. OTHER <br /> 19 <br /> ( r us only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check a9 thatapply) 1 SPILL CONTAINMENT rQ <br /> __ <br /> - ---t ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE_ <br /> ❑ 2. DROPTUBE 1 ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): <br /> 0 1, VISUAL(EXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR). 0 B. TANK TESTING <br /> BIENNIAL TANK TESTING 99, OTHER IV-at y9 cnwrI11 <br /> D{^e,�_ <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YRIM,aOT/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLEDWITH INERT MATERIAL? <br /> gallons <br /> ❑Yea No <br /> � � si fc �RDDD�Io`llo • <br /> CUPAFORM(4/99) '�'a`�`��� n� Formerly SWRCB Form B <br />