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'ONK, O'A <br /> a UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Page of <br /> TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION E�6 TEMPORARY SITE CLOSURE <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (Ch=ck ane item Duly) <br /> [13 RENEWAL PERMIT (Spaeth reason-for local use only) (Spaify reawn-for local use only) ❑ 8 TANK REMOVED IJoI <br /> BUSINESS NAME fs,m=aa FAcarry NAME w oeA-Doing Boer As> FACILITY ID: <br /> 1 <br /> PR 411 <br /> LOCATION WITHIN SITE(optional) <br /> I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br /> TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes bQ No 4M <br /> If-Ya",complete ova page fareech compammrnt <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> V 0lf,�owf In 00 <br /> ADDITIONAL DESCRIPTION(For heal can only) 438 <br /> If.TANK CONTENTS <br /> �a.6�'' N <br /> TANK USE 4J9 PETROLEUM TYPE <br /> 0�_ � <br /> MOTOR VEHICLE FUEL p4.. REGULAR UNLEADED 02. LEADED - 05. JET FUEL <br /> (Ifmvkdwmplene Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER <br /> 03. CHEMICAL PRODUCT COMMON NAME (fmm Haardous Ma¢ruls inventory page) <br /> 441 CAS#limen n wlaw Materials Inventory Page) d43 <br /> ❑4. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑95.UNKNOWN <br /> IDL TANK CONSTRUCTION <br /> TYPE OF TANK I. SINGLE WALL 3. SINGLE WALL WITH LE 5. SINGWALL WITH INTERNAL BLADDER SYSTEM 44J <br /> (Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> []`L DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANKMATERI T ; .;aryunk 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE M. UNKNOWN 444 <br /> (check one hem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/I00%METHANOL Cl 99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATEAL-accordary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 5. UNKNOWN 445 <br /> RI <br /> (Checkm¢iam=nly) 02. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) [110,COATED STEEL <br /> [15. CONCRETE <br /> TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 0 5.GLASS LINING 5.UNKNOWN 446 DATE INSTALLED 449 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Forbnl use only) <br /> (check now item only) <br /> Ng DATE INSTALLED 449 <br /> ❑ <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC 0 999 9 OTHER <br /> UNKNOWN <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT <br /> (Check..=item volt) [32 SACRIFICIAL ANODE (For local uu only) <br /> SPILL AND OVERFILL YEARINSTALLED 45o TYPE(localoanonly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> VflI9:41011,,10 <br /> (Checkeldnewly) Ell SPILL CONTAINMENT Vf1\r,()O" I1 ALARM ❑3 FILL TUBE SHUT OFF VALVE <br /> DROP TUBE U 1 BALL FLOAT ❑4 EXEMPT <br /> efTSTRIKER PLATE <br /> IV.TANK LEAK DETECTION(A deneriloonorm<moo;maingPmgronalwl he noin"n warm m=meal'sancy.) <br /> IF SINGLE WALL TANK(Cheek slaw apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (Che&an=item only) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ®.2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER 91-3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑S TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 651 <br /> gallons A,Yes ❑ No <br /> UPCF(12/99 revised) to Formerly SWRCB Form B <br />