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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (Aro Pages per tank) <br /> ,.// Page _ of _ <br /> TYPE OF ACTION Ll1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Check one dem a*) ❑ T. PERMANENTLYCLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SpscXynason-Imetal use o0y) (SpeaYy chenae-(arlacal use only) <br /> ❑ B.TANK REMOVED 430 <br /> BUSINESS NAME(Same n FACILITY NAME or DBA-Doing Business As) FACILITY IO F ;> 1 <br /> NG D 64 Fotd ¢Lem • . <br /> LOCATION WITHIN SITE(OpfiomO 431 1� <br /> 6'78 N •w (IsaA Wok , (5*A'jV ),G4/,`4j1A/iA <br /> I.TANK DESCRIPTION <br /> TANK IDM TANK MANUFACTURER COMPARTMENTALIZED TANK as ❑ No <br /> fadu� Q4sf91W= <br /> If'Y-V.complel<one pe9a breach mmpanment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> /KA•y ?_db / 3p I OZ-0 6 ZO OdU Z �eatA <br /> ADDITIONAL DESCRIPTION(Fgwecal usa oNy) <br /> 11.TANK CONTENTS <br /> TANK USE 432 ��// PETROLEUM TYPE <br /> O <br /> VL MOTOR VEHICLE FUEL Fe. REGULAR UNLEADED C. 2, LEADED ❑ 5. JET FUEL <br /> p(meked,compels Pstmaks mType) �ID PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATIONFUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑U. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑0. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAURDOUS WASTE(IrcJWee COMMON NAME(hom Hazsmoue M6e4als In.Malpage) CAS N(kam H oludaus Mafedals Insenf nypage) <br /> Uaad an <br /> n95 LJNKN" <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 01. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> (Check arra dem aMy) LS]. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one dem only) ❑ 2, STAINLESS STEEL Rl . STEEL CUD W/FIBERGUSS ❑ B. FRP COMPATIBLE WM00%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-semndsl,tank ❑ 1 BARE STEEL ,❑ 33. FIBERGUSS/PUSTIC 11S. FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (Check one dem only) ❑ 2. STAINLESS STEEL LJ 4. STEEL CUD W/FIBERGUSS ❑ 9. FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GUSS LINING ❑95, UNKNOWN433 DATE INSTALLED <br /> OR COATING � <br /> ❑ 2. ALKYD LINING ❑ 1. PHENOLIC LINING ®��IA <br /> B. UNLINED ❑89. OTHER <br /> CImcM om demo ) (Forlocal use onl) <br /> OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC W3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (Check am item only) ❑ 2. SACRIFICIAL ANODE (Forecalus,flusW <br /> SPILL AND OVERFILL Zoo I <br /> YEAR INSTALLED TYPE(Forbcal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ad Mat applyl 1. SPILL CONTAINMENT �❑ 11, ALARM ❑ 3. FILL TUBE SHUT OFF VALVE_ <br /> 51"'. DROPTUBE p7 2. BALL FLOAT ❑ 4. EXEMPT <br /> 110 3. STRIKER PLATE <br /> ' -'N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all Thal ap l),): IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check one item only) <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE X2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ A. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING 099, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST USED(YPJMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL?gallons ❑Yee ❑No <br /> I fTos�ss�9 <br /> CUPAFORM(4/99) • Formerly SWRCB Form S <br />