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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (taro pages per tank) � / papa _ Of TYPE OF ACTION ❑1.NEW SITE PERMIT 11 `4. AMENDED PERMIT YJ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Chalk.dem Dory) , ❑ PERMANENTLY CLOSED ON SITQ ❑3.RENEWAL PERMIT (Speciynaaon-{orlPW um orxy) (Spaay charge-/orbralun oNJp e. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or CBA-Doing Busmas Aa) FACILITY ID 01 hSTi41� He, ,r fel Rk4r oxu pFff 7X45/556-r LOCATION WITHIN SITE(OW.0 v 431 ��• l �+�OG /_/�• _ ��t� a J 6I�`�(fY(� 1.TANK DESCRIPTION TANK ID 00(- TANK kUNUFACTUflER COMPARTMENTALIZED TANK ❑ Vea o �^ IPYei mmdeta one page tar each m enment. DATE INSJT�ALLLEED(XEEARIMMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(Forlmal use only} II.TANK CONTENTS TANKUSE 432 PETROLEUM TYPE `1.MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑ 2. LEADED ❑ 5.JET FUEL (InswisC,complete Pelmteum Type) ❑lb. PREMIUM UNLEADED . DIESEL ❑ B. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1o. MIDGRADE UNLEADED ❑ 4.GASOHOL 13 N, OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(IMWea COMMON NAME(hrom Hazmdous MateNls ImAn(orypago) CAS a@gm Nazallous Matenals lmenterypage) Used Oil) III.TANK CONSTRUCTION TYPE OF TANK 1. SINGLEWALL ❑ 3. SINGLEWALLWATH ❑ 5. SINGLE WALL WITH INTERNAL BIAODER SYSTEM (Checko.demanM ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN -❑ 4. SINGLE WALL IN A VAULT ❑99OTHER TANK MATERIAL.primarytenk 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Chackanedem.nKi ❑ 2. STAINLESSSTEEL ❑4. STEEL CLAD WIFIBERGLA55 ❑ B. FRP COMPATIBLE Wil 00%METHANOL ❑99. OTHER REINFORCED PIASTIC(FRP) TANK MATERIAL-semMary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ B. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item ony) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGIASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNONM433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 9. PHENOLIC LINING UNLINED N.OTHER For lacaluaa only) (Check orre dem and OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC Cl 3. FIBERGLASS REINFORCED PLASTIC 095. UNKNOWN 434 DATEINSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ d. IMPRESSED CURRENT )Z¢9. OTHER (Check Dna dem only) ❑ 2. SACRIFICIALANODE (Forlmel use oMy) SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal uae only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED tlI a( 'J� (Chock 0lhaf appy) ❑ 1, SPILL CONTAINMENT C �(/ ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE G LVE ❑ 2. DROP TUBE ❑ 2. BALLFLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE N.TANK LEAK DETECTION IF SINGLE WALL TANK(Check as that SEW: IIF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only) ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATICTANKGAUGING(ATG) ❑ S. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ B. TANKTESTING BIENNIAL TANK TESTING 9. OTHER_A2 V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LASTY O/DAY) ESTIMATED QUANTRY OF SUBSTANCE REMAINING 435 1 TANK FILLED W17H INERT MATERIAL? I�_ga0ona E] yes No CUPAFORM(4/99) *el A.merly SWRCB Form B