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F UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Mo pages per tank) �/ Page of TYPE OF ACTION [31.NEW SITE PERMIT ❑ 4.AMENDED PERMIT SI 0. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one Rom only) / ❑ ?. PERMANENTLY CLOSED ON SIT ❑3.RENEWAL PERMIT (SPenymaaan-brboluas w (spent'charge-forlacal use only) ❑ e. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busineaa Aa) FACILITY ID# 1 C H E 7•-5 A u-h� t�c!lp a'L 1,- LOCATION LOCATION WITHIN SITE(OpfioneQ 431 q-5 1.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yea No If'Yen,complete one page br each coma nl. DATE INSTALLED(YEA TANKCAPACITV INGALLON!' ^S NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(FOrbcal use only) (/f/ IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE . MOTOR VEHICLE FUEL ❑ta. REGULAR UNLEADED *. LEADED ❑ 5. JET FUEL (o nm*,I,compW-NtnAum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL ❑ 2. NON-FUELPETROLEUM ❑1c MIDGRADEUNLEADED ❑ 4. GASOHOL 09. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME(fm.Haaandpus Materials Invanbrypepel CAS#(#Om Hazardous M.Wmis Inventory page) ❑ 4. HAZARDOUS WASTE(Izlodea Used 0,0 Q95 UNKNQffi III.TANK CONSTRUCTION TYPE OF TANK SINGLEWALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one dem onry) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT [IN. OTHER TANK MATERIAL-primary lank BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 09. UNKNOWN (Check one from only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W/1 X%METHANOL 13 99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary lank 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 9. FRP COMPATIBLE W1100%METHANOL -�11UNKNOWN (Check ane mm onry) 112. STAINLESS STEEL ❑ 4. STEELCLADWiFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET _ ❑99. OTHER REINFORCED PIASTIC(FRP) D10. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKN0WN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING e. UNLINED ❑99. OTHER (Fw local use only) (Check ane item on1) Y,..� DATE INSTALLED OTKERCORROSION !::ACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1 .85. UNKNOWN 434PROTECTION IF APPLICABLE TION ❑ q. IMPRESSED CURRENT ❑99OTHE(Check ane from only) 1ICIALAN0DE SPILL AND OVERFILL N A YEAR INSTALLED TYPE(For lout use Ony) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check AM that apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check all Mal app ): IF DOUBLE WALL TANK OR TANK WITH BLADDER fChock one item anfn): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ I. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG ❑ ?. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTEBTING BIENNIAL TANK TESTING 99, OTHER 1(1VY V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE UST USED(YRR40IDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yea No FI D * 00l as 7�y'1� !X /* CUPAFORM(4199) • • Formerly SWRCB Form B