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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (aro pages par tank) �7Page _ Of ❑ 5. CHANGE OF INFORMATION) ❑ 8.TEMPORARY SITE CLOSURE TYPE OF ACTION C1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ T, PERMANENTLY CLOSED ON SITE (Crack one dem only) F�L ❑3.RENEWAL PERMIT (SpecNy mexon-larloml use onlYl (Speury chenpa-brlocel use Only) aS. TANKREMOVED 430 BUSINESS NAME(Same as FACILITY NAME or OBA-Ooinp Buaimsa As) FACILITY ID# LOCATION WITHIN SIT E(OPkaM0 431 1.TANK DESCRIPTION TANK MANUFACTURER COMPARTMENTAUZED TANK ❑ Yes ® Nb TANK ID# If 9ei,complete one page br eaGl compartment. Unknown Butler NUMBER OF COMPARTMENTS #J DATE INSTALLED PTARO) TANK CAPACITY IN GALLONS ADDITIONAL DESCRIPTION IFm Nmal use ady) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 2. LEADED ❑ 5. JET FUEL 1.MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED ® ❑ 3. DIESEL ❑ e. AVIATION FUEL (NmaMed,complete Powleum Typo) ❑ib. PREMIUM UNLEADED ❑B9. OTHER ❑ 2. NON-FUEL PETROLEUM [I 1c MIDGRADEUNLEADED ❑ 4. GASOHOL LAS#(horn Hezardaux Mafanals Invenbry pope) ❑ 3.CHEMICAL PRODUCT COMMON NAME(horn Hazanfous Mafebals Invenforypape) ❑ 4.HAZARDOUS WASTE(Includes Used an III.TANK CONSTRUCTION TYPE OF TANK ® 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALLWITH INTERNAL BLADDER SYSTEM EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check om Ilam only) ❑ 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN TANKMATERIAL-pdmery tank ® 1 BARE STEEL r, (Check aro item OrfX ❑ 2. STAINLESS STEEL ❑4. FINFORLAD WIFIBERGIASS ❑ e. FRP COMPATIBLE W1100%METHANOL [195,ONKNOWN (- REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL ❑B5. UNKNOWN NA (Check one Nem only) ❑ 2. STAINLESS STEEL ❑ 4 RSTEEL CLAD EINFORCED #FIBELASTRGFRPS❑ 9 FRP CO NATED ON-C EEOOIBLE JACKET SI 88. OTHER ❑ 5. CONCRETE DATE INSTALLED TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING [1 5. GLASS LINING [195. UNKNOWMI33 OR COATING ❑ PHENOLIC LINING %I B. UNUNED ❑99.OTHER ❑ 2. ALKYD LINING 4. PH (Forlocal use only) Check om Ilam pnl) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATH ODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC PROTECTION UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑ 4, IMPRESSED CURRENT ❑99. OTHER (Forbcal use Dray) (Check am earn only) ❑ 2. SACRIFICIAL ANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) (Creole all bat appy) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM _. ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUBE ❑ 2. BALL FLOAT__ ❑ 4. EXEMPT ❑ 3. STRIKER PLATE V. TANK LEAK DETECTION - ' IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check ane item only): IF SINGLE WALL TANK Check aN(hal ap ly): ❑ 5. MANUAL TANK GAUGING(MTC) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) MONITOR( ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ' ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ e. VADOSEZONE ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER 1-1 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(BIR)• ❑ 8. TANKTESTING BIENNIAL TANK TESTING - 099. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE UST USED(YRIMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLEDWITH INERT MATERIAL? pallom ❑Yes ❑No • Formerly SWRCB Form B CUPAFORM(4/99)