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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FE:7 =TANKSUNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> Pageof <br /> TYPE OF ACTION 01.NEW SITE PERMIT 0 4. AMENDED PERMIT }�5. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE _ _ <br /> (Check one dem oNy) <br /> 113.RENEWAL PERMIT 0 T. PERMANENTLY CLOSED ON SITE <br /> (SPeary mason brkxal use orxy) (Spealy charge rorbcel use only) <br /> ❑ S. TANK REMOVED 430 <br /> BUSJNESSNAME ame as FACILITY NAME WDBA DoingBmi1..1015'a) ` FACILITYID# <br /> UOCATIkNjNTHIN SITE(ppeonep 431 <br /> I.TANK DESCRIPTION <br /> T---A---A K IDN 0 TANK MANUFACTURER <br /> / �3 D 3 /s � 'q COMPARTMENTALIZEDTANK ❑ yea Na <br /> ���//AN <br /> �\J V IYYei,complete one page br eaoh comps ant. <br /> DATE-INSTALLED(YEARIkaq TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> � <br /> ADDITIONAL DEG RIPTION(Farlonl use orM <br /> 11.TANK CONTENTS <br /> �- TANK USE 432 PETROLEUM TYPE <br /> }SL 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED <br /> (R rYaQ cemphnla Polinne.Type) Olb, PREMIUM UNLEADED ��.// 0 S. JET FUEL <br /> ❑ Z. NON-FUEL PETROLEUM I7O DIESEL 0 8,AVIATION FUEL <br /> 0 3. CHEMICALPRODUCT 010. MIDGRADE UNLEADED 0 4. GASOHOL 1:199. OTHER <br /> ❑ 4. HAZARDOUS WASTE(Indudea COMMON NAME loom Ha ni dpua Matedahe ln~lorypage) CAS N(rmm HM3KfOoa Maeda/s Im rhhi page) <br /> Uaed Dip <br /> 1195 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK '�❑ 1. SINGLE WALL 0 3. SINGLEWALLWITH ❑ 5. SINGLE WALL NTH INTERNAL BLADDERSYSTEM <br /> (Check one dem only J"l2 DOUSLEWALI EXTERIOfl MEMBRANE LINER ❑95. UNKNOWN <br /> J-\ 04. SINGLE WALL IN A VAULT 098. OTHER <br /> TANK MgTERIAI-primary tank 0 1 BARE STEEL ���0..,,,///3. FIBERGLASS/PLASTIC 0 5,CONCRETE 095. UNKNOWN <br /> (Checkaneilemon Vt 0 2. STAINLESS STEEL Jd.�, STEEL CUD W/FIBERGLASS 0 B. FRP COMPATIBLE W/100%METHANOL 099 OTHER <br /> REINFORCED PUSTIC(FRPI <br /> TANK MATERIAL-secondary lank 0 1 BARE STEEL 11 3, FIBERGUSS/PLASTIC 08 FRP COMPATIBLE W/lW%METHANOL 095. UNKNOWN <br /> (Check ane item only) 0 X 2. STAINLESS STEEL pp 4. STEEL CUD W/FIBERGLASS 0 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010, COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING COATING 0 1. RUBBER LINED 03. EPDXY LINING 0 5. GLASS LINING 095, UNMOM433 DATEINSTALLED <br /> TA <br /> Check one Rem an ) 0 2. ALKYD LINING 0 4. PHENOLIC LINING 0 e. UNLINED 099. OTHER <br /> Forboal use on ) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> (Check ons item on 0 4. IMPRESSEDCURRENT 099. OTHER <br /> SPILL b1 0 2. SACRIFICIALANODE (For local use ordy) <br /> (Ch ftk AND app LL YEAR INSTALLED TYPE(Forlooel..nl,) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check Withal epply) <br /> 1. SPILLCONTAINMENT 01.ALARM 3. FILL TUBE SHUT OFF VALVE_ <br /> Z. DROPTUBE II <br /> ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK eChi ad that a IF DOUBLE WALL TANK OR TANK VATH BLADDER/Check one item only/: <br /> 01, VISUAL(EXPOSED PORTION ONLY) 05. MANUAL TANK GAUGING(MTG) ❑ I. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 02. AUTOMATIC TANK GAUGING(ATG) 05. VADOSE ZONE . CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR). 0 8. TANKTESTING <br /> BIENNIAL TANK TESTING 00. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE STUSED(YRIMOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WATH INERT MATERIAL? <br /> gallon. <br /> 0 Yea ❑No <br /> CUPAFORM(4/99) • Formerly SWRCB Form B <br />