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CONSOLIDATED FORM <br /> UNIFIED PROGRAM T�1s <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 pages pa lank, <br /> Page <br /> ❑ 5. CHANGE OF INFORMATION) ❑ e. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION 01.NEW SITE PERMIT 04.AMENDED PERMIT <br /> ❑ T. PERMANENTLY CLOSED ON SITE <br /> (Check one dem only) (SpeciycMr0la-brloul vse only) TANK REMOVED 430 <br /> ❑3.RENEWAL PERMIT (Speaiy mason-brloul use onyl 1 <br /> II��L FACRITY ID <br /> ES <br /> BUSINS NAME(Same as FACILITY NAME or OBA-Wirlg}}yi s) <br /> �0 <br /> LO�CAPON WITHIN SITE(Opp Il <br /> /(� <br /> - O F I.TANK DESCRIPTION <br /> COMPARTMENTALIZED TANK <br /> TANK MANUFACTURER c dm <br /> ❑ Yea ° <br /> TANK IDtl f' II'Yef,wmpleb one page Icr.. wmpaent <br /> -f . <br /> 4 o 1 _ 0 <br /> l NUMBER OF COMPARTMENTS <br /> LLTANK CAPACITY IN GALLONS <br /> DATEINSTAED(Y 0) <br /> ,), 600 <br /> ADDITIONAL DESCRIPTION(Forlwal use ony) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUMTYPE ❑� ❑ 5. JET FUEL <br /> REGULAR UNLEADED 1a. R . LEADED 1. MOTOR VEHICLE FUEL ❑ 3. DIESEL ❑ 8. AVIATION FUEL <br /> (If maned,c4mpbb pehpbum Typal ❑1b. PREMIUM UNLEADED ❑ 4 GASOHOL ❑99. OTHER <br /> ❑ 2. NON-FUEL PETROLEUM 014. MIWRADE UNLEADED CAS%(hom Hezallous Mehnals lnuenlpry page) <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(Imm Naxardous Materials Invanlorypage) <br /> ❑ 4, HAZARDOUS WASTE(Intrudes <br /> Used OTU <br /> III.TANK CONSTRUCTION <br /> ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL SLA00ER SYSTEM <br /> TYPE OF TANK ,. SINGLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANKMATERIAL-pnmarytank BARE STEEL ❑ 3. FIBERGLASS I PLASTIC <br /> ❑ 5.CONCRETE [195. UNKNOWN <br /> (Check one ibm°try) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS (30. FRPCOMPATISLEWllW%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-sewndary lank ❑ 3.FIBERGLASS I PLASTIC ❑ 9. FRP COMPATIBLE WI100%METHANOL `❑95 UNKNOWN ���s ) <br /> ❑ 1. BARE STEEL9. X99.OTHER <br /> (Check ons ale-only ❑ 2. STAINLESS STEEL ❑ 4 REINFOR ED PLASTIC(FRP) 010 FCp TED STEELNON-CORRODIBLE JACKET <br /> ❑ 5.CONCRETE DATEINSTALLED <br /> ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 <br /> TANK INTERIOR LINING ❑ ,, RUBBER LINED , UNLINED ❑N. OTHER Forlocal use on <br /> ORCOATING ❑ g ALKYD LINING ❑ 4. PHENOLIC LINING <br /> DATEINSTALLED <br /> Check ores Mm w s��s4M <br /> OTHERC ORROSION ❑ ,. PMANUFAC ROTECTION CATHODIC ❑ 3. FIBERGLASS CURRENT - -j9 OTHER�(,jLYJ-�' (Forlacal uae Dory) <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br /> (CMck Dna Rem Dory) ❑ 2. SACRIFICIAL ANDD YEAR INSTALLED TYPE(Forlpwlusaony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL <br /> ❑ 1. ALARM __ ❑ 3. FILL TUBE SHUT OFF VALVE <br /> (Check aft lhal apply) ❑ ). SPILL CONTAINMENT <br /> ❑ 2. DROPTUSE ❑ 2. WALL FLOAT__ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> lf,, TANKLEAKDETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BIAWER(Cne<k ane item only): <br /> IFSINGLEWALL TANK(Ch"kamthal!ee E31. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 5. MANUAL TANK GAUGING(HTO) <br /> ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ B VADOSE ZONE [3Z. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER ❑ 3. MANUALMONITORING <br /> El 3. CONTINUOUS ATG <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ e. TANKTESTING n <br /> BIENNIAL TANK TESTING ❑99. OTHER /N D Il•� <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN <br /> SLACEANK FILLED WITH INERT MATERIAL4 <br /> ESTIMATED DATE LAST USED(YRR;+OIg^n ESTIMATED QUANTITY REMAINING <br /> -� Bellws ❑Yes No <br /> Foo i3s 7- �t- off <br /> _71� o/ <br /> Formerly SWRCB Form B <br /> CUPAFORM(4189) <br />