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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (run pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION ZNEW SITE PERMIT 134.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) 11S. TEMPORARY SITE CLOSURE <br /> (Chaok orra dam any? ❑ T. PERMANENTLY CLOSED ON <br /> 113.RENEWAL PERMIT (Spaalynason-/orkrcaluseonly) (SpaPYycharge-/orbcal use only) ❑ e. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Buavlaes Aa) FACILITY ID 1 <br /> P A& I 1 NC_ , UA -Food 4 Go44; o 1� <br /> LDDA678 NSI,E WilsrElJ GU �' , �r�eclGdoN , GAliFos,v:�o 41 <br /> 7 1.TANK DESCRIPTION <br /> TANKIDaTANK MANUFACTURER 1a 1'e <br /> COMPARTMENTAL! Yes 11No <br /> LA <br /> • 9l oder-1 / ', " El �aFs If Yescomplete mplete aria page tur each cumpkInent. <br /> )) <br /> DATE INSTALLED(YEAR&IOJ TANK CAPACITY IN GALLONS Elea Jh NUMBER OF COMPARTMENTS <br /> M 20o I �jp OGD 5 /tf !D, LIQ Z 4! <br /> ADDITI RAL D SCRIPTION(ForkW us'any) <br /> II.TANK CONTENTS <br /> ,af TANK USE 432 PETROLEUM TYPE <br /> Lr 1. MOTOR VEHICLE FUEL D 1a. REGULAR UNLEADED ❑ 5. JET FUEL <br /> (1laMdad,compbts Pormleum Type) Bela PREMIUM UNLEADED ❑ ]. DIESEL ❑ B. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMIHAZARDAL OUS <br /> WASCT <br /> TE <br /> COMMON NAME(Avrl Hasardpu3 Materials lnvaMor page) CASa(herll Hazardous Mabrials lnkentoypage) <br /> ❑ 4. HAZARDOUS WASTE(InrJWet <br /> Used Oro <br /> 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK Cl 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Checkonedemomyl W*2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT 0 99 OTHER <br /> TANK MATERIPL-primary Mnk 0 1 BARE STEEL ❑ 1 FIBERGLASS I PIASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (CheckorMdemony) ❑ 2. STAINLESS STEEL V4. STEEL CUD WIFIBERGLASS ❑ e. FRP COMPATIBLE W1100%METHANOL 099. OTHER <br /> REINFORCEQPLASTIC(FRP) <br /> TANK MATERIAL-secondary lank 1 BARESTEEL ❑ 3. FIBERGL.SS/PLASTIC ❑ B. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 114. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ' ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 1110. COATED STEEL <br /> ❑ S.CONCRETE <br /> TANK INTERIOR LINING • Cl 1 RUBBER LINED 113. EPDXY LINING 135. GLASS LINING EI S& UNKNOM433 DATE INSTALLED <br /> OR COATING <br /> [D2. ALKYD LINING ❑ 4. PHENOLIC LINING LY B. UNLINED 1199. OTHER <br /> hack one dem on 1 (Forlocel use only) <br /> OTHER CORROSION C3t MANUFACTURED CATHODIC L•l 1 FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 41s DATE INSTALLED <br /> PROTECTIONION IF IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑0. OTHER <br /> (Check ons dem only) ❑ 2. SACRIFICIAL ANODE (Fprlpcal use only) <br /> SPILL AND OVERFILL Z W I YEAR INSTALLED TYPE(Furbcal uusse�only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ad trot apply) . .�1 SPILL CONTAINMENT �, �ai/s++ • • 011. ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> d2.2. DROPTUSE R12 BALL FLOAT ❑ 4. EXEMPT <br /> IBS 3. STRIKER PLATE <br /> TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Crack an that apply) IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item W04: <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSEZONE Xj CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG - ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING - 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAY) ESTI MATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> galbns ❑Yes <br /> ❑No <br /> TA-Do 515 sgo D I <br /> CUPAFORM(4/99) • Formerly SWRCB Form B <br />