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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Mo Pages M tank) <br /> Pape _ of <br /> TYPE OF ACTION 0 1.NEW SITE PERMIT 0 4, AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) 0 B. TEMPORARY SITE CLOSURE <br /> (Check ono Rem aly) 0 T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (SPenlymason-lorloaluseonly) SpecNaan9e-MbcNumoN) <br /> ❑ e. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or OBA.Doing Business ASI FACIUTY ID a t <br /> Cc�PPLC- l k) S 4CL �SbS <br /> LOCATIONTHIN SITE(Optional) 431 <br /> W <br /> I.TANK DESCRIPTION <br /> TANK 10 ad TANK MANUFACTURER COMPARTMENTAUZED TANK 0 Yes <br /> ❑ No <br /> 5 O� if-YeY.complete are page for eaa compaNmnt. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forloal use pray) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUMTYPE <br /> 0 1. MOTOR VEHICLE FUEL 01a. REGULAR UNLEADED 0 2. LEADED 0 S. JET FUEL <br /> (NMcnmpNte Poholepm Type) 018. PREMIUM UNLEADED 0 3. DIESEL 0 B. AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM 0 tc MIDGRADE UNLEADED 0 4, GASOHOL 0 99. OTHER <br /> ❑ 3. CHEMICALPRODUCT <br /> 0 4. HAZARDOUS WASTE(Indata COMMON NAME(hom Haparcous Manamalmenfory page) CAS 0(han Hasantpw MMNMM krvempry Pagel <br /> Udall 0" <br /> 1195 111,11<141MINI <br /> IN.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (ChackpalbmomY) ❑ 2. OOUBLEWALL EXTERIOR MEMBRANE LINER 095 UNKNOWN <br /> ❑ C SINGLE WALL IN A VAULT 0 99OTHER <br /> TANK MATERIAL-pnmarl lank 0 t DARE STEEL ❑ 1 FIBERGLASS/PLASTIC 0 5. CONCRETE 095. UNKNOWN <br /> (CheckitneiMmpnty) 0 2. STAINLESS STEEL 04. STEELCLADWIFlBERGLASS 0 S.FRPCOMPATIBLEWI11X111,METHANOL 098. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-sacantivy tank 0 t BARE STEEL 0 3. FIBERGLASS I PLASTIC ❑ S. FRPCOMPATIBLE`M100%METHANCL 095. UNKNOWN <br /> (Checkonelhmoray) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD BERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 098. OTHER <br /> REINFORCED PLASTIC(FRP) 010, COATED STEEL <br /> 0 S. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED 0 3. EPDXY UNING 05. GLASS LINING 095. UNKNOWN411 DATEINSTALLED <br /> ORCOATING <br /> ❑ 2. ALI(YD LINING ❑ 6. PHENOLIC LINING ❑ 8.UNLINED ON. OTHER <br /> (ChatodremnsontupylFw local use ody <br /> OTHER PROTECTION <br /> IF PP 0 1, MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 431 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check oa irom oMy) ❑ 2. SACRIFlDIAL ANODE (Forlocal use only) <br /> SPILLANDOVERFILL YEAR INSTALLED TYPE(ForhKal use ariW OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as that apply) 0 1, SPILL CONTAINMENT ❑ 1.ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> 0 1 DROP TUBE ❑ 2. BALL FLOAT 0 C EXEMPT <br /> 0 3. STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK aleck ad that appy): I IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADOSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER 0 3. MANUALMONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 5. TANKTESTING <br /> BIENNIAL TANK TESTING 099 CTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOIDAY) ESTI MATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑Na /n^ <br /> CUPAFORM(4199) Formerly SWRCB Form 8 <br />