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UNirIED PROGRAM CONSOLIDATED FORM1 TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page 1 of 7 r� C18. TEMPORARY SITE CLOSURE TYPE OF ACTION 1,�1.NEW SITE PERMIT C1 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 7 PERMANENTLY CLOSED ON SITE (Check one item only) ❑3.RENEWAL PERMIT (S,.c;ry mason-for local use only) (Speciy change•for Iotal use only) ❑ 6. TANK REMOVED 430 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID N ST E;iZV1CCS LOCATION WITHIN SITE(Opfionaq 431 1.TANK DESCRIPTION D a TANK MANUFACTURER,, COMPARTMENTALIZED TANK ❑ Yes No TANK I �✓ r�/�/ II'Yes',complete one page for each compartment U C DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS j11&,A/0VV IV ADDITIONAL DESCRIPTION(For local use only) It.TANK CONTENTS TANK USE 432 PETROLEUM TYPE El JET FUEL ❑ 1. MOTOR VEHICLE FUEL ❑1a REGULAR UNLEADED FC3 . LEADED ❑ 6AVIATION FUEy (If marked,complete Fb(mleum Type) ❑1b. PREMIUM UNLEADED . DIESEL .❑ 2. NON-FUEL PETROLEUM ❑tc. MIDGRADEUNLEADED . GASOHOL IX99. OTHER ❑ 3. CHEMICAL PRODUCTCAS a(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inrontory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil)95 UtjKN0VN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 2. DOUBLE WALL ❑ 4_ SINGLE WALL IN A VAULT ❑99 OTHER 1. BARE STEEL ��•.��// TANK MATERIAL-primary tank L8-3. FIBERGLASS 1 PLASTIC C15. CONCRETE [:195. UNKNOWN ❑ (Check one item only) ❑ 2. STAINLESS STEEL 04, 4 FORLA D (FRP) s ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER REINFORCED TANK MATERIAL-secondary tank ❑ 1. BARE STEEL 03, FIBERGLASS 1 PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING �6 UNLINED ❑99. OTHER (For local use onl) (Check one item onl) DATEINSTALLED OTHER CORROSION El 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER ❑ 4. IMPRESSED CURRENT (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL .,,...111 YEA//R��INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all(hat apply) 1. SPILL CONTAINMENT V� _ r ❑ 1. ALARM ❑ 3 FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE El 2. BALLFLOAT 14. EXEMPT ❑ 3. STRIKER PLATE IV. TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): IF SINGLE WALL TANK Check all that ap ): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ B. TANK TESTING BIENNIAL TANK TESTING ❑99, OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/M0/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons 11 Yes ❑No Formerly SWRCB Form B CUPAFORM(4/99)