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UNIFIED PROGRAM CONSOLIDATED FORMu TANKS �� W ^ UNDERGRO11)b1'B7 AGE TANKS - TANK PAGE 1 �`� UND STOR (Two pages per tank) TYPE OF ACTION ® l NEW PERMIT (Check one item only) ❑ 3.RENEW ❑ 4'AMENDED PERMIT ❑ 5.CHANGE OF INFO Page-4-.of-7 - IT PERMIT INFORMATION ❑ 6.TEMPORARY TANK CLOSURE - ❑ 7,PE s3o. BUSINESS NAME5 (SP ma reason) (Bpecifyreason) PERMANENTLY CLOSED ON SITE NAM( ameas PACILN#35aor pap-?Ding Husmess As) 3. FAC ID: ❑ 8'TANKREMOVED RALEY'S FUEL STATION#356 �` LOCATION WITHIN SITE(optional) /� - t. 431. (A scaled plot plan with the Iocatu,of the UST system di g C�building,and landmark,shall be submitted to the Iocal agency.) TANK I�{- /d0 432. TANK MANUFACTURER DA A XE a33. COMPARTMENTALIZED TANK ®Yes 0 No a3a. DATE INSTALLE a3s. RXES (YEAR/MO) TANK CAPACITY IN G If"Yes,,conglete one page for each comparnmem GALLONS a36, 2006/C)7i ZOa7 Q 1 q ADDITIONALDESCRIPTI N(Por local use only)2r000 NUMBER OF COMPARTMENTS L^ 437 438. TANK USEPETROLEUM TYPE n• TANK CONTENTS a39. ® 1. MOTOR VEHICLE FUEL (Ifchecked,complete Petroleum Type) ❑ la. REGULAR UNLEADED ❑2. LEADED ® ❑5. JET FUEL "0' 11 2. NON-FUEL PETROLEUM lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS 0 3. CHEMICAL PRODUCT ❑Ic 'GRADE UNLEADED ❑4. GASOHOL COMMON NAME 0 99-OTHER: (mnmdes Daea Oil) PREMIUM U ❑ HAZARDOUS WASTE (6om Hancr000s Materials Inventory page) 441. 9s.UNKNOWN NLEADED 8006-61-9 44 CAS# bum Hazardous Materials Inventory page) 2. ( ❑ III•TANK CONSTRUCTION TYPE TANK on ❑1. SINGLE WALL (Check one item only) ❑3. SINGLE WgLL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443, ®2. DOUBLE WALL MEMBRANE LINER ❑95. UNKNOWN TANK MATERIAL_ ❑1. BARE STEEL ❑4' SINGLE WALL IN A VAULT ❑99. OTHER prvmry tank ®3. FIBERGLASS/PLASTIC (Check one Gem Doty) ❑2. STAINLESS STEEL ❑q. STEEL CLAD W/FIBERGLASS ❑5. CONCRETE ❑95.UNKNOWN ❑8. FRP COMPATBLE TANK MATERIAL-seconds tank RE�ORCED PLASTTC Rp W/100%MET'IWNOL ❑99.OTHER: rY ❑1. BARE$TEFL ®3. FIBERGLASS/PLASTIC ❑8. FRP COMPTIBLE W/]00%METHANOL (Check ow item tmly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET �95 UNKNOWN qq5, REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 0 99.OTHER TANK INTERIOR LINING ❑1.RUBBER LINED ❑5. CONCRETE OR COATING ❑3.EPDXY LINING ❑5.GLASS f.WING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑99.OTHER WN a46. DATE INSTALLED 447. Check one item ad ®6.UNLINED OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN sae_ DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT IfA livable 02.SACRIFICIAL ANODE 1199.OTHER SPILL AND OVERFILL YEAR STALLED 450. TYPE 451, OVERFII.L PROT'ECTT EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®1.SPILL CONTAINMENT 20 PIII.TITE ®l.ALARM 2 _ ®2.DROP TUBE 2 6�� PHIL TITS ®2.BALL FLOAT 2 6 ❑3'FILL TUBE SHUT OFF VALVE ®3.STRIKER PLATE 2 6 PHILTITE _ ❑4.EXEMPT IV.TANK LEAK DETECTION IF SINGLE WALL TANK (A description of the monitoring program shall be submitted to the local agency.) (Check all that apply) 053. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING (Check one item oNy) ElATG 2. AUTOMATIC TANK GAUGING (MTG) 11 L VISUAL(SINGLE WALL IN VAULT ONLY) ( ) ❑6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG ❑7.GROUNDWATER ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING ❑3.MANUAL MONITORING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED OR/MO/DAY) 4" ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. N/A TANK FILLED WITH INERT MATERIAL? 457. gallons ❑Yes ❑ No UPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00