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D dldl �i�.13�t UNIFIED PROGRAM CONSOLIDATED FORM _ UNDERGROUND STORAGE TANKS -TANK PAGE 1 T11NKS. ..�a9es per tank) Page _ al TYPE OF ACTION ❑I.NEW SITE PERMIT ❑ 4. AMENDED PERM IT �. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) ❑ T. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Speciymason-ro0.1 uae wy) fSpeMY cna a Icrlwsl use onl) ^9 Y ❑ 8. TANK REMOVED /]D SINESS NAME(Same as FACILITY NAME or DBA-Dai ass As) FACILITY 10 I S � ( LOCATION WITHIN SITE fOpOanalf /31 !V I �43 I.TANK DESCRIPTION 7O �% Y 7 0 5_ ,a / TANK MANUFACTURER YA111y5 COMPARTMENTALIZED TANK ❑Yes No If'Yee,complete one page for aarr wmpaRmenL DATE INSTALLED(YEARRMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS la1n 8 1 ADDITIONAL DESCRIPTION(Far lwal use coM II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL Tfmar4ed,complete Pe edea.type) ❑1h PREMIUM UNLEADED ❑ 3 DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑I.. MIDGRADE UNLEADED ❑ 4 GASOHOL ❑99. OTHER * CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE fifol.d., COMMON NAME(ft.H.,ad.p.Mandala lme le,pege) CAS 0(fmm N.m..a Meister.m.ol.page) Used On) (! _ cavL5 III.TANK CONSTRUCTION TYPE OF TANK [p,] SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM (Check one item ony) LZ2. DOUBLEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary Unk X, BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check..Rem ony) ❑ 2. STAINLESS STEEL ❑4. STEEL CUD WIF16ERGUSS ❑ B FRP COMPATIBLE W11W11;METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL sewndary lank 19e1 BARE STEEL ❑ 3. FIBERGUSSIPLASTIC ❑ B. FRP COMPATIBLE WII00%METHANOL 095. UNKNOWN (CnwX o.lfemonW 2, STAINLESS STEEL ❑ 4. STEEL CUD W/FISERGUSS ❑ 9. FRP NON-CORROOISLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) 0 1 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING Cl I RUBBER LINED ❑ EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOM433 DATEINSTALLED OR COATING ❑ 2. ALKYD LINING . PHENOLIC LINING ❑ fl UNLINED ❑89. OTHER (Check ons item anl) ��ar (Forlwal use on ) POTHER ROTECTION IF ON bld MANUFACTURED CATHODIC ❑ 3 RBERGUSS REINFORCED PLASTIC ❑95. UNKNOWN 4U DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 099. OTHER (Check Ona it..onyJ ❑ 2. SACRIFICIAL ANODE (F.rbcal me only) SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use muy) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check al Nab appy) ISkt SPILL CONTAINMENT 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUSE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV.TANK LEAK DETECTION IF SINGLE WALL TANK Checka6 beef ap )' IF DOUBLE WALL TANK OR TANK WITH BUDDER(@Iec4 one item on ): ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) �❑ 11. VISUAL(SINGLE WALLIN VAULT ONLY) 132. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSEZONE a17.j. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG 11T. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION ISIR)a 118. TANKTESTING BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PUCE ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? 9a11.ns ❑Yes ❑No CUPAFORM(4199) 4 FoMedy SWRCB Form 1