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UNIFIED PROGRAM CONSOLIDATED FORM s/61 f 0� TANKS UNDERGROUND STORAGE TANKS -TANK PAGE I (two pages per tank) [II NEW SITE PERMIT Page_of TYPE OF ACTION ❑ 4 AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check weilemonly) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifyreuon-farlacni aonb) (Specifymuon-forlocalmonly) ❑ 8 TANKREMOVED BUSINESS NAME(Same as FACMITY NAMEor DBA Doing Baainm As) FACILITYID: 1 J LOCATION WITHIN SITE(opoonap 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landirmurks shall be submitted to the local agency.) T-AN/K ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑ No 434 T/1,L S� Ya',wmplc a oro pa8e for e h compuonenL i DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(For local uae only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 410 ❑I. MOTOR VEHICLE FUEL ❑ Is. REGULAR UNLEADED 02. LEADED ❑5. JET FUEL (IfnatkN cantplea Pewlean Type) ❑lb. PREMIUM UNLEADED 03. DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED 114. GASOHOL 99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(nom Hod.Matmala lnvemorypage) I CAS#(fiomHmrdou Meteriala lnvsnary page) 4R ❑4. HAZARDOUS WASTE (Incloh Uaaa W) ❑95.UNKNOWN 111. TANK CONSTRUCTION TYPEOFTANK 1. SINGLE WALL 03. SINGLE WALL WITH LJ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chock one item only) EXTERIOR MEMBRANE LINER 095.UNKNOWN - ❑2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primuyin* 0 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC U 5.CONCRETE 0 95.UNKNOWN 4M (Check one asrn only) ❑2.STAINLESS STEEL ❑4. STEEL CLAD WJFIBERGLASS ❑S. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCEDPLASTIC(FRP) TANK MATERIAL-secondary lank U 1. BARE STEEL U 3. FIBERGLASS/PLASTIC US. CONCRETE U 95.UNKNOWN N5 (Caeckone iononly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WJFIBERGLASS ❑S. FRP COMPTIBLE W1100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) )TIO.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 0b.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTRER (Checks.n item ooly) (Far lawlus only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44g DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For loal vee only) SPILL AND OVERFILL YEAR INSTALLED 4% TYPE(w lure only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 1 452 (Oecka110areMly) ❑1 SPILL CONTAINMENT 0 ALARM. ❑3FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(Adeampuon o(tacmoniaring program"I M submiuNm do,]..I agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one ilnnonly) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑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 ❑990THER 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 SVTRCB Form B