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natant UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS_TANK PAGE i (two pages per tank) Pegc or_ / TYPE OF ACTION ❑I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one iam only) - ❑ 7 PERMANENTLY CLOSED ON SITE Elas 3 RENEWAL PERMIT (Specityreon-forleenluseonly) (Specify reason-fm lmel use only) ❑ STANK REMOVED Z 30 BUSINESS NAME(Sameas FACRITYNAMEor DBA-Doing Business As) FACILITY.ID: » 0 " I lNO LOCATION WITHIN SITE(Optional) 431 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and laradmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER - 433 COMPARTMENTALIZED TANK ❑Yes ❑ No 4m TJ4as� 7��' Ya",mmpkeone page for Conti parhnenk DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(For local one,only) 438 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑I. MOTOR VEHICLE FUEL ❑ la. REGULARUNLEADED 02. LEADED 05. JET FUEL (IfmarkeAcmnplaa Petroleum Type) ❑ lb. PREMIUM UNLEADED ❑3. DIESEL '[16.AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ In. MIDGRADE UNLEADED ❑4. GASOHOL 99.OTHER [13. CHEMICAL PRODUCT COMMON NAME(fmm Hawdous Moaners lnvenary page) I CAS#(fiam Ha>srdom Materials Inventory page) MZ [14. HAZARDOUS WASTE (Includes Uxd Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPEOFTANK LJ 1. SINGLE WALL 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkonenarronly) EXTERIOR MEMBRANE LINER 095. UNKNOWN ❑2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-p6marytark LJ 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5.CONCRETE U 95. UNKNOWN 444 (Check one iamonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPTIBLE W1100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary took U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC C1 5. CONCRETE U 95. UNKNOWN 445 (Check one ism only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 09. FRP COMPTI13LE W/100%METHANOL ❑99.OTHER 11 REINFORCED PLASTIC(FRP) 10.COATED STEEL ❑5.CONCRETE TANK INTERIOR LINING LJ I.RUBBER LINED 0 3.EPDXY LINING S.GLASS LINING 95.UNKNOWN 446 DATEINSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Clack..a kon only) (Far local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Chak one item only) ❑2 SACRIFICIAL ANODE (Fm local use only) SPILL AND OVERFILL YEARINSTALLED 4% TYPE(localuseonly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chackalltlutapply) ❑1 SPILL CONTAINMENT ❑I ALARM. ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A de option ofine nowioring pmgmm shall be submined an the local agency.) IF SINGLE WALL TANK(cheekall that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chackaoeitemonly) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 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 [-199 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