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Y_ FIE1. UNIFIED PROGRAM CONSOLIDATED FORM �I TANKS p" 1 UNDERGROUND STORAGE TANKS -TANK PAGE 1 V .4191 lP 6 (two pages per tank) TYPE OF ACTION L^iI NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) I ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (21,mity reawn-fsloceluseonly) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESSN (Sameas FACT NAMEor DBA-Doing Business FgCILITY ID: I LOCATION WITHIN SITE(optimm) 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 1D `/��y5432 TA K MANUFACTURER 433 COMPARTMENTALIZED TANK []Yes ❑ No 434 :J as It"Yes",complete ore page for each compamment. DATE INST.9!LLED( EA O) 033 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 i . 2B t" ADDITIONAL DE CRIPTION(Formealmepmy) 438 II.TANK CONTENTS TANK USE 439 �PEETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL BI Is. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL !marked complete Pcmolcum Tye) /❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM [Ile. MBDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(ft.Hauroms Materiels honso y page) "I CAST!(fiom Hesardoua,Mamriab Imenwy page) 442 [14. HAZARDOUS WASTE (IncludesUsed Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPEOFTANK 0 1. SINGLE WALL 3. SINGLE WALLWITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIORMEMBRANFLINER ❑95. UNKNOWN X2. DOUBLE WALL [14. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-pdmey look 0 1. BARE STEEL 3. FBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FBERGLASS ❑8. FRP COMPTIBLE W/100°/METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary took LJ 1. BARE STEEL . FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING I.RUBBER LINED U 3.EPDXY LINING C1 5.GLASS LINING 95.UNKNOWN 446 DATE INS AALLEDD 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER C>q-f z 6 , . f�/ (Check one item only) (For local use only) OTHER CORROSION ❑IMANUFACf(IREDCATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC 0 9 UNKNOWN 448 DATEINSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED &&, 452 (Check all that apply) &SPILL CONTAINMENT 0/- �f5�I ALARM 11A, K3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE b2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE Re 4 �1 IV.TANK LEAK DETECTION(A description ofthe monitoring program shall be submitted an the local ageuy.) IF 51NOLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) �❑,/1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) El VADOSE TONE D(2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING 0 9 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B