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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (taro pages per tank) <br /> Page <br /> TYPEOFACTION 111.NEW SITE PERMIT 0 4, AMENDED PERMIT D 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> (Chectrpne@emonly) �❑ .�_ <br /> 7. PERMANENTLY CLOSED ON SITEr <br /> . DiB <br /> 03.RENEWAL PERMIT (Spenrynasan-brbaluw only) (Specify cMlga-brbcal vxa oMy) TANK REMOVED 430 Y <br /> BUINESS NAME(Same as FACILITY NAME or OBA-Doing BusiMss As) s FACIUTYION rte' 1 <br /> s� of µ�� Ar F k- -�tv 5� <br /> LOCATION WITHIN SITE(O1pMnag /31 ��� L� / "(AOSl55lo�{ <br /> G ✓YlctP/✓� <br /> 1.TANK DESCRIPTION <br /> TANK 10 If O I TANKMANUFACTURER . COMPARTMENTALIZED TANK ❑ Yes o <br /> AN,�_N'_LA/ j� If'Yes.,mmplNe one page br eac Compartment <br /> DATEINSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> Gv `f 4/_ <br /> ADDITIONAL DESCRIPTION(Farlocal uxa only) <br /> II.TANK CONTENTS <br /> ��fs TANK USE 432 PETROLEUM TYPE <br /> j�L 1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 0 22. LEADED 0 5. JET FUEL <br /> (I/ Med,compleb Pefrobum Type) 010. PREMIUM UNLEADED J�\3. DIESEL 0 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM 0 1c MIOGRADE UNLEADED 11 4. GASOHOL 0 99. OTHER <br /> 11 3. CHEMICAL PRODUCTCAS%pmm Hazardous Matedals lmm�torypage) <br /> COMMON NAME(Mm Nezallous Mafenals/nwnbrypage) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Uaod 00) <br /> n95 UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK 1SINGLE WALL D 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check on,item onW 11 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> 0 4, SINGLE WALL IN A VAULT D99. OTHER <br /> TANK MATERIAL-pnmalTtanN X, <br /> BARE STEEL 0 3, FIBERGLASS/PLASTIC 05 CONCRETE 095. UNKNOWN <br /> (Check one from oMy) 0 2, STAINLESS STEEL 11 4. STEEL CLAD W/FISERGUSS 0 B. FRP COMPATIBLE WIIW%METHANOL 099. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary lank 0 I BARE STEEL ❑ 3. FIBERGLASS/PLASTIC 0 8, FRP COMPATIBLE W/100%METHANOL 095. UNKNOWN <br /> (CheckaMitem-*) 0 2, STAINLESS STEEL 0 4. STEEL CUD WIFIBERGLASS D 9. FRP NON-CORRODIBLE JACKET 089.OTHER <br /> REINFORCED PLASTIC(FRP) 010.COATED STEEL <br /> 0 5. CONCRETE <br /> TANK INTERIOR LINING 0 1. RUBBER LINED ❑ 3. EPDXY LINING 0 5. GLASS LINING 095. UNKNOWN433 DATE INSTALLED <br /> ORCOATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING5. UNLINED 099.OTHER Forbcal use onNl <br /> (Check..Mm onl) DATE INSTALLED <br /> OTHER CORROSION ❑ 1, MANUFACTURED CATHODIC 0 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> D 4. IMPRESSED CURRENT 89. OTHER (Farlocal uaeonly) <br /> (Check one item oMy) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use Doty) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED ry 6 <br /> (Check as that app(Y) ❑ 1. SPILL CONTAINMENT 0 1, ALARM _ 11 3. FILL TUBE SHUT OFF VALVE <br /> 0 2. DROP TUBE 11 2. BALL FLOAT 0 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.;TANK LEAK GETEGTON <br /> IF SINGLE WALL TANK Check as Ihate )' IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one i(ema <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) 0 5. MANUAL TANK GAUGING(MTG) 0 1. VISUAL(SINGLE WALL IN VAULT ONLVI <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATO) 06. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> 0 3. CONTINUOUSATG D T. GROUNDWATER ❑ S. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 8. TANKTESTING al y <br /> BIENNIAL TANK TESTING 9. OTHER_��D(U L <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE UST US(�ED(YMOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLEDWITH INERT MATERIAL? <br /> t4a 9e8ona 0Yes No <br /> CUPAFORM(4/99) Fonerly SWRCB Form B <br />