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UNIFIED PROGRAMCONSOLIDATED FOR <br /> L�fANKS <br /> UNDERGROUND STORAGE TANKS-TANK <br /> pages per tank) <br /> U Page _ of <br /> TYPE OF ACTIONNEWSITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ S.TEMPORARY SITE CLOSURE <br /> (Check one item onW ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SPerlynesm-lorboal we only) (SP.,yons'.-whl vss ony) ❑ S.TANK REMOVED 430 <br /> BUSINESS NAME(Esme a FACILITY NAME or DBA-Dsing Bwimss Aa) <br /> FACILRY ID�' 1 <br /> Ri <br /> tTi <br /> G�Call� <br /> N 51 (Oplionso �1 l <br /> Z0 Al ��la." <br /> I.TANK DESCRIPTION <br /> L TANK MANUFAC^TU/RER COMPARTMENTALIZED TANK 11 Yes No <br /> 3 61 V ( RryeC,complete one page for each shp.rMent <br /> 7L '!\ NUMBEROFCOMPARTMENTG <br /> (YEARRAO) TANK CAPACITY IN GALLONS <br /> � �SCRIPTION(Porbcal use may) <br /> II.TANK CONTEN75 <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ S.JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1.. REGULAR UNLEADED ❑ 2. LEADED 8.AVIATION FUEL <br /> (rymukW,compleM Pelmleum Type) 01b. PREMIUM UNLEADED ❑ 3. DIESEL <br /> ❑ 2. NON-FUEL PETROLEUM tc. MIDGRADE UN LEADED ❑ I. GASOHOL ❑e9. OTHER <br /> ❑ 3.CHEMICAL PRODUCT COMMON NAME(Som Hazatdoua sMs"slnwnMrypage) CASY(hom Hazanioua Mafedab lnvsnlorypage) <br /> ❑ 4, RAZARDOUS WASTE(Includes <br /> Used Gal <br /> ` Ill.TANK NNSTRUC=noN <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WITH WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINERWN(Check one item--W ❑ 2. DOUBLEWALL 0 4. SINGLE WALL IN A VAULTTANK MATERIAL- nlnery tank ❑ ]. FIBERGUSSIPIASTIC ❑95. UNKNOWN�.1. BARE STEEL(Check ane item oMy) ❑ 2. STAINLESS STEEL D 4. STEEL CILAO <br /> REINFORCED PILABER FRPSIBLEW/100%METHANOL ❑99.OTHER <br /> TANK MATERIAL-saconauy lank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ B. FRP DOMPATISLE W/100%METHANOL El 25. UNKNONT! <br /> LA <br /> (Check one item only) ❑ 2. STAINLESS STEEL 4 REINFORCED FLAB <br /> (FRP) 010.COATED STEEL CLAD WIFIBERGLASS 9, FRP ffiEELOOIBLE JACKET ❑99.OTHER <br /> ❑ 5. CONCRETE <br /> DATE INSTALLED <br /> TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ 5.GLASS LINING 095. UNKNOWN433 <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ems+ a: UNl1NE0 99. OTHER Forlxaluse on ) <br /> (Checkoneibman ` DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODID ❑ 3, FIBERGLASS REINFORCEDPLASTIC 95. UNmom 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (Forlouluse oNy) <br /> (Check core item any) ❑ 2. SACRIFICIAL ANO DE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILLANDOVERFIUL - YEAR INSTALLED TYPE(Forbcal use oMy) <br /> (Chackeametapply) ❑ 1. SPILL CONTAINMENT iV NVl ❑ 1. ALARM 0 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUSE ❑ 2. BALL FLOAT__ ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> -N.TANK LEAK DETECTION <br /> IF DOUBLE Ila 1 TANK 00.TANK VRTH BLADDER Check one item on <br /> IF SINGLE WALL TANK Check as fini SeEll <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING INTO) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG 1 1. ❑ T. GROUNDWATER ❑ 3. MANIMLMONITORING <br /> ❑ 4. STATIBTICALINVENTORY RECONCILIATION(SIR). ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING 099. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />