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., -k 0�\ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> T1;.NK3 <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 p} <br /> rages cerfank) ■ <br /> / Page <br /> TYPE OF ACTION ❑I.NEW SITE PERMIT ❑ C AMENDED PERMIT P'. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br /> (Cnxk one item only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specdynasan-krbceluu <br /> orxy) (SpeNy cnarpe-brlwal ase amyl ❑ B. TANK REMOVED 430 <br /> SMESS NAME(Some a a FACILITY NAME or OBA-Doi usiness As) FACILITY ID/ 1 <br /> \ v W4 , <br /> LOCATION WITHIN SITE(Optlonaq 431 <br /> LW <br /> S C <br /> I.TANK DESCRIPTION <br /> TANK{OY © (%�-7 ® 5- ,t / TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea No <br /> �i/(1t► �AI11}5 It-Yes,wmplele Dna page tar earls compartment <br /> DATEINSTALLED(YEARWO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Farbcal use only) <br /> It.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1.MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑ 2.LEADED 1:15. JET FUEL <br /> -(/rmadM1eE,complete Penaleum Type) ❑lb PREMIUM UNLEADED ❑ ] DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADEUNLEADED ❑ 4.GASOHOL 1199 OTHER <br /> IfiL. CHEMICALPRODUCT <br /> COMMON NAME(ham HaraEous Mafenals mvenforypage) CAS a(from Hasadous <br /> Wed Mafenab Inwnbry page) <br /> ❑ 4. Woo <br /> OiQOUS WASTE Pn4udes <br /> Uso <br /> III,TANK CONSTRUCTION HDCV s-U J <br /> TYPE OF TANK P J, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> � <br /> (check one dam Dory) DOUBLE WALL EXTERIOR MEMBRANE LINER 11 9S. UNKNOWN <br /> ❑ C SINGLE WALL IN A VAULT 09 OTHER <br /> TANK MATERIAL-pnmaD tank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Check we sum oni,) ❑ 2. STAINLESS STEEL ❑4. STEEL CUD WIFIBERGUSS ❑ B. FRP COMPATIBLE W11D0%METHANOL 09. OTHER <br /> REINFORCED PLASTIC IFRP) <br /> TANK MATERIAL-secondary Lank 15Ct BARE STEEL ❑ 3 FIBERGLASS I PLASTIC ❑ B, FRP COMPATIBLE W11M%METHANOL 095. UNKNOWN <br /> (Cheri one Mem onty) 2. STAINLESS STEEL ❑ 4. STEEL CUD WIFIBERGUSS ❑ 9 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATEDSTEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ - EPDXY LINING 05 GLASS LINING ❑95. UNKNOM433 GATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING . PHENOLIC LINING El 8. UNLINED El 99 OTHER <br /> Mck one nem oral,) <br /> (FPrbcal uss Dory) <br /> OTHER CORROSION �FAMANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED RUSTIC 095. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (Check one item or4y) 02, SACRIFICIAL ANODE (Forbcal ase only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forro lvs-d*) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Cluck aM that apply) 'Ek 1. $PILL CONTAINMENT t.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ A. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> ' N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK fCkaFk all that SPW: IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSEDPORTION ONLY) Cl 5. MANUALTANK GAUGING(MTG) �❑ 11 VISUAL(SINGLE WALLIN VAULT ONLY) <br /> 112. AUTOMATIC TANK GAUGING(ATG) D 8. VADOSEZONE Jae$- CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESRNG <br /> BIENNIAL TANK TESTING 099, OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED RIMO/DAY) ESTIMATED QUANTITY OF SUB.St NCE REMAINING 435 1 TANK FILLED HATH INERT MATERIAL? <br /> .3 S gauam E]Yes ❑Na _ <br /> CUPAFORM(4/99) 40 Formerly SWRCB Form <br />