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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 1 <br /> (two pages per tank) <br /> ' _' Paso�or AL <br /> TYPE OF ACTION ❑I NEW SITE PERMIT ❑ 4 AMENDED PERMIT j 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE <br /> (Chakma itemaay) ' ` ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 3 RENEWALPERMIT (Spaifyomum-fmloaluacanly) (Spaifyraam-forloaluseoay) ❑ 8 TANK REMOVED 430 <br /> BU INT:_SS NAME(Sameaa FACIUTINAMEor DBA-Wing Baana,A,) 3 FACILITY <br /> s <br /> L1c�.��GRs__. <br /> LOCATION WITHIN SITE(opmwn - 431 <br /> E 5 c (o., of si 1 '1 2 �C _ 5 00 eT <br /> 1.TANK DESCRIPTION (A scaled plot plan With a location ofthe UST systemeluding buildings and landmarks shall be submitted to the local agency.) <br /> TANK fD# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK es ❑ No 434 <br /> 5 N 0 4 XE If"Ya",amplae up page for each 0mr anent. <br /> DATE INSTALLED(YEAR/MO) 4335 TANK CAP ITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> MAUtA I 6 1 Pop <br /> ADDITIONAL DESCRIPTION(For mealase day) 438 <br /> II.TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE - <br /> XL MOTOR VEHICLE FUEL , REGULAR UNLEADED ❑2.LEADED ❑S. JET FUEL <br /> (IfrwrkW<omplet,Pmoleum Typc) r b PREMIUM UNLEADED [13. DIESEL [16. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM Ic. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER _ <br /> ❑3. CHEMICAL PRODUCT COMMON NAME (from llaardom Materiel,Inventory page) 41 CAS#(fmm Haaamos Materials memory page) <br /> 0.4. HAZARDOUS WASTE <br /> ( Used Oil) <br /> ❑95.UNKNOWN ✓ /4 <br /> r9 <br /> III. TANK CONSTRUCTION <br /> TYPEOFTANK Lj I. SINGLE WALL Lj 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (Check one item only) EXTERIOR MEMBRANE LINER 095.UNKNOWN <br /> 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> TANK MATERIAL-primary wok I. BARE STEEL M 3. FIBERGLASS/PLASTIC $. CONCRETE C 95. UNKNOWN 494 <br /> (Checkoneitemoay) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100°%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary teak L1 1. BARE STEEL 3..FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 <br /> (Chat one itarmly) ❑2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> [15. CONCRETE <br /> TANK INTERIOR LINING DLRUBBERLINED 0 3.EPDXY LINING .GLASS LINING Mr5.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER <br /> (Check ane item aaly) (Far local use only) <br /> OTHER CORROSION �.1(�{�,�.MANUFACTURED CATHODIC Ji FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN DATE INSTALLED 449 <br /> PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER <br /> (CbaJromitemoay) ❑2 SACRIFICIAL ANODE (For loW we only) <br /> SPI.LAND OVERFILL YEARINSTALLED 450 TYPE(Iocal ae may) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (ChakallWazaWIY) J$15PILL CONTAINMENT X] ALARM3 FILL TUBE SHUT OFF VALVE <br /> DROP TUBE � BALL FLOAT EXEMPT <br /> ❑3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A descriptionofda moatoriag program shall W aubmiredto Ne localapney.) <br /> IF SINGLE WALL TANK(chat an tom apply) - 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (Chakoneitemoay) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTC) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE A2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑STANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITYOF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> N 1.0f - Ndo)' gallons 1vlR ❑Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />