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e2 h f2ul"- <br /> UNIFIED PROGRAM CONSOLIDATED FAN <br /> ORM <br /> UNDERGROUND STORAGE TANKS-T GE i <br /> TYPE OF A LON 0 I NEW SrrE PERMrr 0 4 AM721DED PERMIT O 5 CHANGEIX'INFORMATION O T PERMATEMPO�NENIT.Y CLOSED ON SITE <br /> (Chair aK imnadY) 430 <br /> eauoe-C«lod TANK REMOVED <br /> ❑ 3 RENEWAL PERMIT (SpeoCY«a0n-Tarl4W uu«4y) (sped% t <br /> BUSINESS NAME(S. FACILITY NAME«DBA-odeaBA:) FACILITY ID: <br /> 3 <br /> LOCATION WITHIN SITE(()Pd ) <br /> w -sTa � % <br /> PTION (A Bale <br /> L TANK DESCRId plot Plan With um--of the UST system including bui(dmgs and butd�s shall <br /> `ZED TANK ❑Yes�Naa mry) <3( <br /> O5i50�5 432 TANK MANUFACTURER o3 <br /> TANK ID q [JiC <br /> (J N /l N o w A/ Y«.oe4 arm wa �A ewpne�C <br /> a -_- 434 NUMBER OF COMPARTMENTS 07 <br /> DATE INSTALLED(YEAR/MO) 425 TANK CAPACITY 1N GALLONS © n1 <br /> V " KN OW A/ BO <br /> 411 <br /> ADDITIONAL DFSCRIPTION(F«lood oee Y) <br /> D.TANK CONTENTS <br /> 44c <br /> TANK USE 459 PETROLEUM TYPE <br /> OLMOTOR VFkBCLEFUEL 01a. REGULAR UNLEADED 02. LEADED 05. JET FUEL <br /> pCmulaaww,e«Pwok«^TYPe) ❑lb. PREMIUM UNLEADED 03. DIESEL 06.AVIATIONTUEL p / <br /> 02.NON-FUEL PETROLEUM Ole. MIDGRADE UNLEADED 04.GASOHOL 99.OTFBR S 7r0 ✓ F <br /> J <br /> 03.CHEMICAL PRODUCT <br /> COMMONNAME(rmmx.ma«s Md«idpmrmtwy pae) wt CASK<rmmx+vdau Mra;d+mmwr pqe) <br /> 04. HAZARDOUS WASTE <br /> 95.UNKNOWN <br /> ID. TANK CONSTRUCTION <br /> TYPEOFT . SINGLE WALL 3. SINGLE WALL WITH SI <br /> S. NGLE WALL WITH INTERNALBLADDER SYSTEM 443 <br /> J (Chad«alma«dr) EXTERIOR MEMBRANE LINER 095.UNKNOWN <br /> ❑2. DOUBLE WALL 0 4. SIGNLE WALLIN VAULT ❑99. OTHER <br /> TANKMATLRIAI.-piomY 1. BARE STEEL 3. FBER(BASS/PLASTIC 5.CONCRETE 93.UNKNOWN <br /> 444 <br /> (O p my) 0 2. STAINLESS STEEL 114- SI EEL CLAD W/F)BERGLASS 08 FRP CWMBLE W/lW%N EHIANOL 099 99.OTTffR <br /> REINFORCED PLASTIC(FRP) <br /> 7ANK MATERIAL-umn4uy«nk M 1. BARE STFFL 3. FIBERGLASS/PLASTIC 5. CONCRETE <br /> 95.UNKNOWN say <br /> (Chad one oun.1,) N 0 N C ❑2. STAINLESS STEEL 0 4. STEEL.CLAD WMBERGLASS 0 S. FRP COMPHBLE W/100 METHANOL 0 99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑m.COATED STEEL <br /> ❑5. CONCRETE <br /> T----RI---G I.RUBBER LINED 3.EPDXY LINING S.CLASS LINING 95.UNKNOWN 444 DATE INSTALLED M] <br /> 4 OR COATTNG 4"L5N E ❑2 ALKYD LINING ❑4 PHENOLIC LINING V UNLINED 0 99 OTHERIF <br /> 444 DATE INSTALLED 44� <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC �95 UNKNOWN V /<A; <br /> �u C <br /> PROTECTION IF APPLICABLE PROTECTION 0 4IMPRESSED CURRENT 0 99 OTHER <br /> 2 SACRIFICIAL ANODE (F«lod®only) <br /> (t5mi mc�mn my) ❑ 432 <br /> SPILLAND OVERFILL YEAR INSTALIM 454 TYPE(Imlme**) <br /> LF <br /> 4si OVERFILL PROTECI70N EQUIPMENT:YEAR INSTALLED <br /> l (med�alldm Wiy) O I SPILL CONTAINMENT 0 ALARM 03 FILLTUBESHUTOFF VALVE <br /> ❑2 DROP TUBE IV O N r 0 2 BALL FLOAT ❑4 EXEMPT � O N r <br /> ❑3 STRIKER PLATE Y- <br /> IV.TANKLEAKDETECnON(Ad pored[ m -dne«ew4aamib l-bgitWwtlamed4am y.) <br /> 09:E2 <br /> LL TANK(aadd nr wdr> 49 IF DOBLE WALLTANK OR TANK WITH BLADDER 451��/ (erred.i..uY) <br /> XPOSEDPORTIONONLY) .f(5MANUALTANKGAUGING(MIG) ❑1VISUAL(SINGLEWALLINVAULTONLY)C TANK GAUGING(ATG) ❑6 VADOSE ZONE 0 2 CONTINUOUS IN ERSTITIALMONITORING <br /> OUS ATG ❑7 GROUNDWATER 0 3 MANUAL MONITORING <br /> AL INVENTORY RECONCILIATION ❑STANK TESTINGNNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> 455 4" <br /> ESTIMATED DATE LAST USED(YR/MO/1AY) ESTIMATED QUANITIY OF SUBSTANCE REMAINING 456 TANK FILLED WHH INERT MATER ALT <br /> K N O W N 0 tv i5 gallons ❑Yes No <br /> L) IVUPCF(11199 revised) 10 Formerly SWRCB Form B <br />