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a1 U N IF I EDF ROG RAM C ONSOLI DATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank)E: <br /> Page _ or <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ /. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) <br /> ❑ B.TEMPORARY SITE CLOSURE <br /> (Check ors Rem Dory) ❑ T. PERMANENTLY CLOSED ON SITE <br /> 03.RENEWAL PERMIT fSpecRysason-lorbcal uas only) ISpecy charge-brlxal use only) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Same es FACILITY NAME or DBA.Doing Buainem As) <br /> FACILITY IDN D 1 <br /> ,a <br /> LOCATION WATHIN SITE(Opeonso 431 e <br /> 7431 Er <br /> I.TANK DESCRIPTION <br /> TANK 100 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No <br /> If-Yes',complete one page for each cnmpamnent. <br /> DATE INSTALLED(YEARJIA0) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> G $L 1 600 <br /> ADDITIONAL DESCRIPTION(Forbcal use 000 11 <br /> II,TANK CONTENTS <br /> :OREH"LE <br /> 7FUEL <br /> 432 PETROLEUM TYPE <br /> (K1. MOTD tat REGULAR UNLEADED �. LEADED ❑ S. JET FUEL <br /> nead, 01b. PREMIUM UNLEADED 0 3. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NOND 1c MIDGRADE UNLEADED 0 4. GASOHOL 099. OTHER <br /> ❑ 3. CHECOMMON NAME(hsrl Hardous Meredals Imsnbrypage) tHzd/dpeSMafedalsInwnlorypape)❑ 4. HAZs <br /> Use <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK SINGLE WALL 11 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER [195. UNKNOWN <br /> (Check one Rem only) 02 DOUBLE WALL 0 4. SINGLE WALL IN A VAULT <br /> [199 OTHER <br /> TANK MATERIAL-primary lank x1 BARE STEEL 0 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (Check one dem Only ❑ 2. STAINLESS STEEL 04 STEEL <br /> D LCI-APLASTIC <br /> ERGI.A 0 B. FRP COMPATIBLE Wr10g%METHANOL 099. OTHER <br /> RE <br /> TANK MATERIAL wcon.ary tank ❑ 1 BARE STEEL 0 3. FIBERGLASS I PLASTIC 0 B. FRP COMPATIBLE WI109%METHANOL 095. UNKNOWN <br /> fCheck me Item only) 0 2. STAINLESS STEEL 0 4, STEEL CI-AD <br /> REWFORCED FIBERGFRP) 09 FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> [110, COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING <br /> ❑ 5. GLASS LINING 095. UNKNOM433 DATEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 6. PHENOLIC LINING . UNLINED ❑99. OTHER Forlxal use on ) <br /> (Check one Ram on ) DATEINSTALLED <br /> OTHER CORROSION ❑ 1, MANUFACTURED CATHODIC 0 3, FIBERGIASS REINFORCED PLASTIC UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (Forlocaluseonly) <br /> (Check oneltem only) D 2. SACRIFICIALANODE N fi <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Farbcal use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Chad go that apply) 0 1 SPILL CONTAINMENT ❑ 1. ALARM __ 0 3, FILL TUBE SHUT OFF VALVE <br /> )1',`/R ❑ 2. DROPTUBE 0 2. BALL FLOAT D 4, EXEMPT <br /> 0 3, STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> W : <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER Check One item only): <br /> IF SINGLE ALL TANK(aleck all that ae& <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) MANUAL TANK GAUGING(MTG) 0 L VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) 0 S. VADGSEZONE 0 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. MANUAL MONITORING <br /> 0 3. CONTINUOUSATG 0 T. GROUNDWATER <br /> 0 4. STATISTICAL INVENTORY RECONCILIATION(SIR) 0 B. TANKTESTING <br /> BIENNIAL TANK TESTING D99, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> �D gallons O Yes Na <br /> F� oa / - s <br /> p 5155' r <br /> CUPAFORM(4/99) ' n ,r/ /^ Formerly SWRCB Form B <br />