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UNIFIED PROGRAM CONSOLIDATED FORM <br />�� II <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 TANKS <br />!IK'P Pa9 !M f kJ <br />Paye _ of _ <br />TYPE OF ACTION ❑ 1. NEWSITE PERMIT ❑ e. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br />(Check erre Hem drlfj <br />❑3. RENEWAL PERMIT 11T. PERMANENTLY CLOSED ON SITE <br />(Sp-ty-P, hrMCN vee orNy) !$pecyy Cllenpe-Bvbcalus aMy) <br />❑ B. TANK RFM(1VFI1 <br />BUSINESS NAME (Seine Is FACILITY NAME w DBA - Doing Busmen Aa) <br />FACILITY ID P <br />�'trtFF �4cryt� kC7CQLY <br />LOCATION WITHIN SRE (OpeorMp J31 <br />6'Ma S N f- co at - S fouatry�- <br />1. TANK DESCRIPTION <br />TANK ID a <br />TANK MANUFACTURER <br />COMPARTMENTALIZED TANK Yee ❑ No <br />II NaY, PomplNe Dna Depa fw eatA Companmenl. <br />DATE INSTALLED(YEARH D) <br />TANK CAPACITY IN GALLONS <br />NUMBER OF COMPARTMENTS <br />r/GM D fittaN� <br />pi <br />ADDITIONAL DESCRIPTION(FrM use Ony) <br />IL TANK CONTENTS <br />TANK USE e32 <br />PETROLEUM TYPE <br />1G 1. MOTOR VEHICLE FUEL <br />❑ la. REGULAR UNLEADED <br />❑ 2. LEADED <br />❑ 5. JET FUEL <br />(B maM1ep, mmproro PwrProum type) <br />❑D�I,Klb. PREMIUM UNLEADED <br />❑ 3. DIESEL <br />❑ 6. AVIATION FUEL <br />❑ 2. NON-FUELPETROLEUM <br />M 'P MIDGRADE UNLEADED <br />❑ a. GASOHOL <br />0 9. OTHER <br />❑ 3. CHEMICALPRODUCT <br />COMMON NAME (M1om HazalCoua Mata slnwnrorypaye) <br />CAS B(M1om Hazartloua Marohals lnwnrorypape) <br />❑ a. HAZARDOUS WASTE(fndw . <br />UoKr om <br />0 95 UNKNOWN <br />111. TANK CONSTRUCTION <br />TYPE OF TANK <br />t SINGLEWALL ❑ 3. SINGLEWALVMTH ❑ 5. SINGLE WALLW1TH INTERNAL BUDDER SYSTEM <br />[0 <br />!Check onsdem only) qe 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br />❑ 9. SINGLE WALL IN A VAULT <br />❑ N. OTHER <br />TANK MATERIAL -pinery WN 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 0 9. UNKNOWN <br />fcwk orre?rein Doty) ❑ 2. STAINLESS STEEL Q'C STEEL CUD W(FIBERGIASS ❑ 8. FRP COMPATIBLE W(lW%METHANOL ❑B9. OTHER <br />REINFORCED PLASTIC FRP) <br />TANK MATERIAL secweary mink 0 1 BARE STEEL ❑ 3. FIBERGUSS(PUSTIC ❑ 8. FRP COMPATIBLE W1100% METHANOL 095. UNKNOWN <br />(Cheok.Hem PnW ❑ 2. STAINLESS STEEL ❑ a. STEEL CUD W(FIBERGLASS ❑ 9. FRP NON- CORRODIBLE JACKET ❑89. OTHER <br />REINFORCED PLASTIC (FRP) 1110 COATED STEEL <br />❑ 5. CONCRETE <br />TANK INTERIOR LINING ❑ 1. RUBBER UNEO ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 1195 UNKNOWNQ3 DATE INSTALLED <br />OR COATING <br />❑ 2. ALKYD LINING ❑ A PHENOLIC LINING Ly6. UNLINED 099. OTHER <br />ClNckon*b . ) (Fwlpaluae ) <br />CORROSION <br />OTHERPROTECTION IF ON <br />PROTECTION IF APPLICABLE <br />0 I MANUFACTURED CATHODIC <br />❑ 3. FIBERGLASS REINFORCED PLASTIC ❑ 95. UNKNOWN a3A <br />OATE INSTALLED <br />PROTECTION <br />I <br />❑ a. IMPRESSED CURRENT 1199. OTHER <br />fCb kone Ham only) <br />❑ 2. SACRIFICIAL Ah <br />fForb lu oeny) <br />SPILL AND OVERFILL <br />YEAR INSTALLED <br />TYPE (Wor rluaa Pdy) <br />OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED "?e <br />(CMck atl that aPPM <br />1. SPILL CONTAINMENT <br />11FVAL <br />❑ 1. ALARM 3 . FILL TUBE SHUT OFF VALVE <br />❑ 2. DROP TUBE <br />❑ 2. BALL FLOAT ❑ A. EXEMPT <br />❑ 3. STRIKER PLATE <br />N. TANK LEAK DETECTION <br />IF SINGLE WALL TANK (Check as t8ata <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER fC)eck acre item <br />❑ 1. VISUAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING (MIG) <br />❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br />❑ 2. AUTOMATIC TANK GAMING (ATG) 116. VADOSEZONE <br />❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br />� <br />LM'3. CONTINUOUSATG ❑ T. GROUNDWATER <br />❑ 3. MANUALMONITORING <br />❑ 4. STATISTICAL INVENTORY RECONCIUATION(SIR). ❑ 8. TANKTESTING <br />BIENNIAL TANK TESTING <br />❑ B9. OTHER <br />V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br />ESTIMATED DATE LAST USED(YRIMO/ Y)IMATED <br />M <br />EST OUANTITY OF SUBSTANCE REMAINING 035 TgNN FILLED WITH INERT MATERIAL? <br />r4R. <br />pallona <br />❑ raa ❑ No <br />CUPAFORM (4199) Formerly SWRCB Form B <br />