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0 a U NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) F / P., _ of JA4'. CHANGEOF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ T. PERMANENTLY CLOSED ON SITE (Check aha nem only/ ❑].RENEWAL PERMIT (5peciy moan-brlocal uta only) lS.vaM/c/'a^pe-brlocal ate antyl ❑ 8. TANK REMOVED 430 FACILITY 10 N SINESS NAME(Sameu FACILITY NAME or DBA-Dai minus As) � 1 \ _ /-) OTS LOCA TIONWITHINSITE(OadOA00 431 jj I.TANK DESCRIPTON TANK MANUFACTURER COMPARTMENTAU2EDTANK ❑ Yaf ❑ Na TANK % If Yaa',wmplete one page br aarJlwmpaemenc O �� TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS DATE INSTALLED((EARIM ADDITIONAL DESCRIPTION(Forbcal me amy) IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5, JET FUEL a REGULAR UNLEADED ❑ 2. LEADED 1. MOT,mPlVEHICLEFUEL ❑ ] DIESEL ❑ e. AVIATION FUEL -llrmaM1ed,comptt.efs Pohvlsum Type) ❑10 PREMIUM UNLEADED ❑g9. OTHER ❑ 2. NON-FUEL PETROLEUM ❑1. MIOGRADEUNLEADEO ❑ 4 GASOHOL CAS N(hpm Hazardous Materials lnwnbry page) *] CHEMICAL PRODUCT COMMON NAME lImm Naunfam Ma:eNBlnaenlory page) //F-- ❑ 4. HAZAROOUSWASTE(Inclue-1 Uf"Gln ��(Z L-GLfLJ 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1, SINGLEWALL ❑ ] SINGLEWALLWTH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM -1�y/' E%TERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one dem Doty) Ti- OOUBLEWALL 'Q 4 SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-phmary tank 1 BARE STEEL ❑ ] FIBERGLASS IPLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check my item only) ❑ 2. STAINLESSSTEEL ❑4 STEEL CLAO WIFIBERGLASS ❑ B. FRP COMPATIBLE WIICO:'e M ETHANOL 0 9. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-I cnneary lank 1 BARE STEEL ❑ ] FleERGLASS I PLASTIC ❑ B. FRP COMPATIBLE W1100%METHANOL 95. UNKNOWN ❑ (Check one item Only 2. STAINLESS STEEL ❑ 4 STEEL CLAD WIFIBERGU55 ❑ 9 FRP NON-CORROOI BLE JACKET ❑99. OTHER REINFORCED PLA STiC(FRP) 010 COATED STEEL ❑ 5 CONCRETE OATEINSTALLEO TANK INTERIOR LINING 1 RUBBER LINED ❑ ] EPDXY LINING ❑ 5. GLASS LINING C]95. UNKNOWN 433 OR COATING 2. ALKYD LINING 4. PHENOLIC LINING ❑ e. UNLINED 99 OTHER OTHE0. (Forbcal ua any) GATE INSTALLED (Check ane item onl I a.� 0 95 OTHER CORROSION bl-A MANUFACTURED CATHOOIC ❑ ] FIBERGLASS REINFORCED FUSTIC (399. OTHER 4]4 PROTECTION IF APPLICABLE PROTECTION ❑ 4, IMPRESSEOCURRENT (Forlwal me onl%I (Check one item my) ❑ 2. SACRIFICIALANOOYGARINSTALLEO TYPE(Forlwal me OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED SPILL AND OVERFILL i (Check an that apply) 1. SPILL CONTAINMENT 1.ALARM ❑ ]. FILL TUBE SHUT OFF VALVE � �� ❑ 2. OROPTUSE ❑ 2. BALL FLOAT__ [I 4. EXEMPT ❑ 0. STRIKERPLATE IV.TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check ene item on ): IF SINGLE WALL TANK Check all that ap ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 1. VISUAL(UPOSED PORTION ONLY) ❑ 5. MANUAL TANK GANGING(NTC) �p ❑ 8. VACOSE ZONE .1'�2. CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING(ATG) 0 T GROUNDWATER ❑ 5. MANUALMONITORING ❑ ]. CONTINUOUSATG ❑ 4. STATISTICALINVENTORY RECONCILIATION(SIR) ❑ B. TANKTESTING BIENNIAL TANK TESTING ❑99. OTHER�- V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED GATE UST USED(YR/MOIOAY) ESTIMATED OVANTItt OF SUBSTANCE PEMAINING 4 TANK FILLED WITH INERT MATERIAL? -�ga0om ❑Ym []No PD Formerly SWRCB Forrr CUPAFORM(4/99)