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=- - <br /> 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORMUNDERGROUND STORAGE TANKS -TANK PAG <br /> Pape _ of <br /> ACHANGE OF INFORMATION) 0 0,TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT D 4. AMENDED PERMIT D T. PERMANENTLY CLOSED ON SITE <br /> (Check om iKm Doty•) <br /> 03.RENEWAL PERMIT (SPeclfl'/saran-brbcel uae omyl (Spemry charge-brloW vse Dory) ❑ 9.TANK REMOVED 43D <br /> 1 <br /> BUSINEBBE,N,A,ME(Same as FACILITY NAME or DBA.Doing Buaineas As) D / <br /> FACILITY IDR <br /> LOCATI THIN SITE(Opeane9 131 ( o^ <br /> `J\ I:TANKID�ES/CRIPTION V <br /> TANKI00 TANKMANUFAOTURER COMPARTMENTYLLIZED TANK one papa laDY.r eaNscomparUmns. <br /> 6-� Th.Xc-SCD <br /> if TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> DATE INSTALL 0(YEa"o) /0),00 0 <br /> OoOO <br /> D 3 <br /> ADDITIO1NAL ESORIP"ON(For jecal use ordy) <br /> - IL TANK CONTENTS <br /> TANKUSE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> ❑LLAR UNLEADED. REGULAR ❑ 2. LEADED <br /> 1. MOTOR VEHICLE FUEL ❑ 3. DIESEL D 6. AVIATION FUEL <br /> (II Mac,comptero Po(roteum Type) PREMIUM UNLEADED ❑99. OTHER <br /> ❑ 2. NON-FUEL PETROLEUMc MIDGRADE UNLEADED 0 4. GASOHOL <br /> ❑ CASa(ImmllBzilCOpa Mdtenels lnwntorypape) <br /> 3. CHEMICALPRODUCT <br /> COMMON NAME(hom HazeNous Mefecals InwnforypMel <br /> 0 4. HAZARDOUS WASTE(Induces <br /> Uses DO <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> (Check om item only) )51z. ODUSLEWALL 4,SINGLE WALL IN A VAULT D99. OTHER <br /> 95, UNKNOWN <br /> TANK MATERIAL-phmary unk 1 BARE STEEL ❑,/3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE <br /> (Chec <br /> ❑k one item only) D 2. STAINLESS STEEL ➢C4, STEEL CUD W/FIBERGLASS [3e. FRP COMPATIBLE W/100%METHANOL ❑0 OTHER <br /> e REINFORCED PIASTIC IFRP) <br /> TANK MATERIAL-aaumcar,unk 0 1 BARE STEEL 03. FIBERGLASS/PLASTIC ❑ e. FRP COMPATIBLE WI100%METHANOL 099. OTHER- <br /> UNKNOWN <br /> (CM1eck orM Ram ontyl 0 2. STAINLESS STEEL �4. STEEL CLAD WIFIBERGLASS 09, FRP NON-CORRODIBLE JACKET <br /> REINFORCED PLASTIC(FRP) 10 COATED STEEL <br /> D 5. CONCRETE DATEINSTALLED <br /> TANK INTERIOR LINING 0 1. RUBBER LINED 0 3. EPDXY LINING ❑ 5. GLASS LINING 095. UNKNOWN433 <br /> ORCOATING D 4. PHENOLIC UNING 8. UNLINED 099. OTHER Forlocaluse ) <br /> D 2. ALKYD LINING DATEINSTALLED <br /> (Check one nem onl) <br /> OTHER CORROSION ❑ t. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑BS. OTHER (Fort ocal us..oty) <br /> (CM1eck omitem anty9 ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forteal use only) <br /> (Check elf that apply) ❑ 1. SPILLCONTAINMENT 0 1. ALARM __ 0 3, FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ,� 0 2. BALL FLOAT_ 0 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> W.TANK LEAK DETECTION V..... <br /> ' IF DOUBLE WALL TANKOR TANKWITH BLAOOER(CM1eck Dna item on ): <br /> IFWALL TANK Check ate fhafd D 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 1, VISUAALL((ExEXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTC) - <br /> ❑ S. VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING <br /> D 2. AUTOMATIC TANK GAUGING(ATG) 0 T GROUNDWATER <br /> ❑ S MANUALMONITORING <br /> 0 3. CONTINUOUS ATG <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 a. TANKTESTING <br /> BIENNIAL TANKTESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YWMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> 435 TANK FILLED WITH INERT MATERIAL? <br /> peliona ❑Yes 0 No <br /> • • Formerly SWRCB Form B <br /> CUPAFORM(4/99) <br />