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UNIFIED PROGRAM CONSOLIDATED FORM 3 \fl� <br /> ii TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 f�Ul n3 <br /> (fvro Pages per tank) <br /> Page _ of <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4.AMENDED PERMIT CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Ch.konaltamenW ❑ T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT (Sperry Mae"-Iorlooa/use, <br /> only) (SpaalycMlge-brbnl use nnryl ❑ S. TANK REMOVED 430 <br /> BUSINESS NAME( me as FACILITY NAME or DBA-Doing Business As) FACILITY IDI I, 1 <br /> LOCATI THIN SITE(OpSOM0 431 <br /> I.TANK DESCRIPTION <br /> TANK IOC TANKMANUFACTURER <br /> w /A <br /> ^✓CJI Y' rI S c-0 COMPARTMENTALIZED TANK ❑ Yea Na <br /> /ly ✓w( D 3 TR 11-Yes',wmplete one page br este comps ant. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 000 <br /> ADDITIONAL DESCRIPTION(Farbcal use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ��11,/2. LEADED ❑ S. JET FUEL <br /> �(if ackM,complete Peholeum Type) 01b. PREMIUM UNLEADED /�.DIESEL ❑ B. AVIATION FUEL <br /> 0 2. NON-FUEL PETROLEUM tc MIDGRADE UNLEADED ❑ 4.GASOHOL 099, OTHER <br /> 0 3. CHEMICAL PRODUCT <br /> 0 4. HAZARDOUS WASTE(IIrtIWes COMMON NAME(hom HamrEous Mafetlals Inwntory/mgs) CAS Y(M1om Hasesfpua Materials lmenfcry page) <br /> Uaao Dig <br /> 173 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK '0 1. SINGLE WALL 03, SINGLE WALL WITH 0 5. SINGLE WALLWATH INTERNAL BLAODER SYSTEM <br /> MY <br /> (C <br /> ck ons item only) Yo_ DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> -� �Q 4. SINGLE WALL IN A VAULT 099. OTHER <br /> TANK MATERIAL-palmary lank 0 1 BARE STEEL ���D...///3. FIBERGLASS I PLASTIC 0 5, CONCRETE OBS. UNKNOWN <br /> (Check one item any) 0 2. STAINLESS STEEL )as8, STEEL OLID WIFIBERGLASS ❑ B. FRP COMPATIBLE W(100%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC FRP) <br /> TANK MATERIAL-se Mary lank 0 1 BARE STEEL ��aa-3 3. FIBERGLASS I PLASTIC ❑ e. FRP COMPATIBLE WIIW%METHANOL 095. UNKNOWN <br /> (Checkolmitemonry) 11 2. STAINLESS STEEL yr(.. STEEL DIAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET 089. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED 0 3. EPDXY LINING 0 5. GLASS LINING D 85. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER <br /> Forl <br /> Chock om Mm on ) <br /> xal use pnl) <br /> OTHER CORROSION Cl 1. MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 0 9. OTHER <br /> (C),eckPM item only) ❑ 2. SACRIFICIAL ANODE (Forksal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwbul me oNy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (CMck aq that apply) 1. SPILL CONTAINMENT 111.ALARM 3. FILL TUBE SHUT OFF VALVE_ <br /> 1 <br /> �2. DROP TUBE _1 ❑ 2. &ILL FLOAT ❑ 4. EXEMPT <br /> D 3. STRIKER PLATE <br /> .< <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check 00 that a IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one demo ): <br /> D 1, VISUAL(EXPOSED PORTION ONLY) 11 5. MANUAL TANK GAUGING(MTG) 01. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 11 2. AUTOMATIC TANK GAUGING(ATG) 0 8. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG 0 T. GROUNDWATER 0 3. MANUAL MONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 S. TANKTESTING <br /> BIENNIAL TANK TESTING - 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE ST USED(YRIMOI p '.j ESTIMATED QUANTITY OF SyBSTANCE REMAINING 435 TANK FILLED WATH INERT MATERIAL? <br /> V/ U qa%OAf 0 Yea 0 No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />