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OVA ©0!!, <br /> �NIFIED PROGRAM CONSOLIDATED FORM <br /> ` J1 TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (r (fwo pages pertank) <br /> Pepe _ of <br /> (Checkpm Nem onyJ _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT CHANGE OF INFORMATION) ❑ S TEMPORARY SITE CLOSURE <br /> ❑3.RENEWAL PERMIT ❑ T. PERMANENTLY CLOSED ON SITE <br /> (Speaynason-Iprhxa/PISS prM19 (Sp4ay olurpe-b -a 8sa anry) ❑ 5. TANK REMOVED 43g <br /> .;vNAME a n FACILITY NAME or OBA-Doing Buainms Aa) FACILITY ID/ <br /> p � , <br /> LOCATI THIN SITE(OpSoneQ 431 <br /> I.TANK DESCRIPTION <br /> TANK y„IOLa ��.J3 �3 TANK MANUFACTURER <br /> / / • /✓1 � �I D / G 'sem COMPARTMENTALIZED TANK ❑ Yas No <br /> ✓ J V 11'Yn;mmplale one papa br eaU mmpa aril. <br /> DATE INSTALLED(YEARIh10) TANK CAPACITYIN GALLONS NUMBER OF COMPARTMENTS <br /> c�o0 <br /> ADDITIONAL DESCRIPTION(Fprklcal vee P:*) <br /> II.TANK CONTENTS <br /> �-,- TANK USE 432 PETROLEUM TYPE <br /> }SL 1.MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑ 2. LEADED <br /> (N AaE,complete PstMaum Type) 01e. PREMIUM UNLEADED �./ 5. JET FUEL <br /> ❑ 2. NON-FUELPETROLEUM FTV_ DIESEL ❑ S.AVIATION FUEL <br /> ❑ 3.CHEMICAL PRODUCT 1:3 1. MIDGRADE UNLEADED ❑ 4. GASOHOL 089. OTHER <br /> ❑ 4 HAZARDOUS WASTE(IMhAes COMMON NAME(hpm Haultlow MatedLs lnronloypaga) CAB#ptom Happen:Ma Mals lnw,,,q page) <br /> UaPP op <br /> El 95 UNKNOWN <br /> IN.TANK CONSTRUCTION <br /> TYPE OF TANK '�❑ 1, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Checkpneltemonly) 1+'Lo_ DOUBLEWALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> 0 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary lank 01, BARE STEELAw��❑,///3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Checkone inm.*) 112, STAINLESS STEEL K STEEL CLAD WIFIBERGUSS ❑ B. FRP COMPATIBLE WfIW%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC IFRP) <br /> TANK MATERIAL-seconoary tank 0 1 BARE STEEL .3. F18ERGUSS/PLASTIC 11S. FRP COMPATIBLE W/1W%METHANOL ❑95. UNKNOWN <br /> (Check one item ony) ❑ 2. STAINLESS STEEL pp ., STEEL CO W/FIBERGUSS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> 1110 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ,, RUBBER LINED DATE INSTALLED <br /> ORCOATING ❑ 3. EPDXY LINING ❑ 5. GUSS LINING ❑95. UNKNOWN433 <br /> (Check onaifemo ) 0 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ S. UNLINED ❑99. OTHER <br /> OTHERFo'ImNPIseon ) <br /> PROTECTION <br /> CORROSION IF ON ❑ 1, MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED RUSTIC ❑95. UNKNOWN �4� GATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT 11 99. OTHER <br /> (LMckpM item ony) ❑ 2. SACRIFICIALANODE (Forlocal PI:eonly) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fcrkeal PISS ony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check eN that apply) <br /> 1. SPILLCONTAINMENT ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE_ <br /> 2 DROP TUBE lI <br /> ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> Tv.TANK LEAK DETECTNJN <br /> IF SINGLE WALL TANK Check eNHref a IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item ont,) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5, MANUAL TANK GAUGING IWC) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ S TANKTESTING <br /> BIENNIAL TANK TESTING <br /> ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE WT USEO(YR/MOIOAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 1 TANKFILLED WITH INERTMATERIAL9 <br /> gallon: <br /> ❑Yes ❑No <br /> CUPAFORM(4199) ( Formerly SWRCB Form B <br />