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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Mn pages per tank) <br /> Page _ or _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT Itl 5. CHANGE OF INFORMATION) ❑ e.TEMPORARY SITE CLOSURE <br /> (Check one darn only) ❑ 7. PERMANENTLY CLOSED ON SITE ^� y <br /> 113.RENEWAL PERMIT (SpeGy mason-loracal use orNY) (Specht,change-lorlocal use only) 11 8.TANK REMOVED 430 v / <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing BAs) FACILITY ID 1 <br /> 3 GO 4707 <br /> usin�A <br /> LOCATION WITHIN SITE( phonag 431 <br /> 70 <br /> I.TANK DESCRIPTION <br /> TANK ID Al TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea ❑ No <br /> 01 <br /> Z/ 7 0 ,,S� If'Yei,complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlacal use only) - <br /> If.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1.. REGULAR UNLEADED ❑ 2. LEADED ❑ 5.JET FUEL <br /> (II markeC,complex Petroleum Type) ❑15. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUELPETROLEUM 01c MIDGRADE UNLEADED ❑ 4. GASOHOL 099. OTHER <br /> ❑ 3.CHEMICAL PRODUCTCAS N(horn Hezandous Malonals lomnlary page) <br /> COMMON-MME(f..Hazartlous Mafenab Immnlorypaya) <br /> ❑ 4. HAZARDOUS WASTE(IrMuras <br /> us.a an <br /> 0 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check oneitem only) ❑ 2. DOUBLE WALLEXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> �❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Check onelam only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE Wil 00%METHANOL 0 9. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ B. FRP COMPATIBLE WI100%METHANOL 13 95. UNKNOWN <br /> (Check one dam only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CIAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET _ 099. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOM433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ e. UNLINED 099. OTHER Forlxel use only) <br /> (Check ora Ilam cow <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PIASTIC ❑95. UNKNOWN 434 GATE INSTALLED <br /> PROTECTION IF APPUCABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (Checkone ilemonly) 112. SACRIFICIAL ANODE (Fwlocal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Foracal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check as Thal apply) ❑ 1 SPILLCONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> N. TANK LEAK DETECTION. <br /> IF SINGLE WALL TANK(Check all that appIvj: IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item onl : <br /> ❑ i, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LA U D(YRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL] <br /> gellom ❑Yea ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form 8 <br />