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(v IID Q� <br /> r <br /> UNIFIED PROGRAM CONS ILIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION C 1.NEW SITE PERMIT 0 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) C 9. TEMPORARY SITE CLOSURE <br /> (Lheckom item onlJl . C T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (sp.-y.--brloalum orNy) (Spsary tlMnga-brlwul wsoMy) ❑ S. TANK REMOVED 430 <br /> FACIUTYIDN 1 <br /> PFACIL.�7E(Same as FACILITY NAMEor DBA Deng Susan As) k ' <br /> SITE(Opfromg I.TANK OESLRIPTION <br /> 'r U,S/ TANKMANUFACTURER LOMPARTMENTif Y'2 mmplef ane page foTANK orr es each mmpanrnenL <br /> (YEARRAO) - TA"GAPACITY IN GALL0CRIPTION(Forkcal me.NY) <br /> IL TANK CONTENTS <br /> ,..J ❑TANK USE 132 PETROLEUM TYPE ❑ S.JET FUEL <br /> ldt.MOTOR VEHICLE FUEL �1a. REGUTARUNLEADED 2. LEADED <br /> (Il mark4d,mmpbfe Petroleum Type) Cin. PREMIUM.UNLEADED - Cl 3. DIESEL [1 8.AVIATION FUEL <br /> C 2.NON-FUEL PETROLEUM 0 tg. MIDGRADEUNLEADED C 4.GASOHOL 099.OTHER <br /> C 3.CHEMIGLPRODUCT COMMON RAME@om Hazardous Materials lnrenlarypege) CASN(M1om Haxallous Mebdab/munlorypege) <br /> C 4.HATARDOUS WASTE(IMudes <br /> Used OR) <br /> TIL.TANK CONSTRUCTION <br /> TYPE OF TANK 01, SINGLE WALL C 3. SINGLE WALL WITH Q 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE UNER 095. UNKNOWN <br /> (Muck ono iNm oMy) �2. DOUBLE WALL [34.SINGLE WALL IN A VAULT <br /> [199.OTHER <br /> TANKMATERUL-pNnary tank 0 1. BARE STEEL . FIBERGLASS/PLASTIC ❑ 5. CONCRETE <br /> 095. UNKNOWN <br /> (CMck one ibm omy) ❑ 2. STAINLESS STEEL 04. <br /> STEEL CUD P/LIBERGASTIC FRPS 0 B. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REINF <br /> RCED <br /> TANKMATERIAL-semrAary bnk C 1. BARESTEEL LY]?FIBERGLASS/PLASTIC C B.FRP COMPATIBLE W1100%METHANOL C95. UNKNOWN <br /> (Check one it..oNy) C 2. STAINLESS STEEL C 4. C 9' FRP NON-CORRODIBLE JACKET 0 99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> 0 10.COATED STEEL <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ ]. EPDXY LINING ❑ 5.CUSS LINING 095. UNKNOWN433 GTEINSTALLED <br /> ORCOATING ❑ C LINING C S.UNLINED C 99. OTHER <br /> ❑ 2.ALKYD LINING 4. PHENOLIC Farlma/u4a mll <br /> Cluck om item o ) DATE INSTALLED <br /> OTHER CORROSION ❑ 1, MANUFACTURED GTHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC C95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER , <br /> ❑ 6. IMPRESSED CURRENT (Fwlxaluu oMy) <br /> (CmckomilemonM 0 2. SACRIFICIALANODE. <br /> YEAR INSTALLED TYPE(Foll me onW OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL <br /> (Check aN that apply) 0 1, SPILLCONTAINMENT ❑ 1.ALARM _- ❑ . FILL TUBE SHUT OFF VALVE_ <br /> 0 2. DROPTUBE 0 2. BALL FLOAT__ C 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION 9 <br /> IFSINGlEWALLTANK ChackaBmata I : <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER Lhack one Item on <br /> ❑ 1, VISUAL IMPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING WTG) 01. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 0 2. AUTOMATIC TANK GAUGING(ATG) C B. VADOSEZONE OL G,ZWIN000S INTERSTITIAL MONITORING <br /> 0 3. CON INUOUSAT(3 - C T. GROUNDWATER C ]. MANUALMONITORING <br /> 0 4. STATISTIGLINVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIALTANKTESTING ❑99, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GTE LAST USED(YR,%OIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL'! <br /> gallon 0 Yes C No <br /> Formerly SWRCB Form B <br /> CUPAFORM(4/99) <br />