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4 � IS107 -� ! 2f17 UNIFIED PROGRAM CONSOLIDATED FORM TANKS 6°� U OERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) I &/14W �,� Page-of_ OF ACTION &i NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ✓ ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSESS NAME(Same as FACILITY NAME or DBA-Doing Business Aa) FACILITY ID: I Cly to L_ ' i :E LOCATION WITHIN SITE(Optional) 431 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.) TANK ID# TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 a3 ;I /� ✓� sNV W.V if-Yes",complete one page for each comparmirnt. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(For local use only) 438 _ If.TANK CONTENTS 1 TANK USE 439 PETROLEUM TYPE ❑1. MOTOR VEHICLE FUEL ❑ Ia. REGULAR UNLEADED ❑2. LEADEDaa' ❑5. JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL 2. NON-FUEL PETROLEUM p Ic. MIDGRADE UNLEADED ❑4. GASOHOL .OTHER 03. CHEMICAL PRODUCT C MMON NAME (from H-d..Material,Inventory page) 441 CAS#(from Hawdow Materials Inveno 442 ❑4. HAZARDOUS WASTE p 7 page) (Includes Used Oil ❑95.UNKNOWN /// -r' III. TANK CONSTRUCTION TYPE OF TANK SINGLE WALL U 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT 1199. OTHER TANK MATERIAL-primary ank . BARE STEEL 03. FIBERGLASS/PLASTIC U 5. CONCRETE 95 UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary ank 1. BARE STEEL 3. FIBERGLASS/PLASTIC U 5. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [--Ill. FRP COMPTIBLE W/100%METHANOL � ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING U I.RUBBER LINED 0 3.EPDXY LINING U 5.GLASS LIMNG U 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING �UNLINED (Check one item only) ❑99 OTHER (For local use only) OTHER CORROSION :11 MANUFACTURED CATHODIC [:13 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT (Check one item only) ❑2 SACRI FICIAL ANODE 13 99 OTHER SPILL AND OVERFILL (For local use only) YEAR INSTALLED 450 TYPE(local use only) 4sl OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED 452 (Check all clot apply) ❑1 SPILL CONTAINMENT ❑2 DROP TUBE ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE .C/ .� ❑2 BALL FLOATS �� ❑4 EXEMPT ❑3 STRIKER PLATE --FV.TANK LEAK DETECTION(A description of the monitoring program shall be submimd m the local agency.) IF SINGLE WALL TANK(Check.] th,tapply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING MTG (Check one item only) ( ) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) [:16 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/-PERMANENT CLOSURE IN PLACE ESTIMATEDDATE LAST USED(YR/MUO/DAY) 455 ESTIMATED NTITY OF SUBSTANCE REMAINING 456 e� TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes No UPCF(12/99 revised) 10 Formerly SWRCB Form B