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UNIFIED PROGRAM CONSOLIDATED FORM C/j <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK P <br /> (two pages per ank O <br /> Page _ of\ _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE 1 <br /> (Check one Nem owi�❑,�•7. PERMANENTLY CLOSED ON SITE v' <br /> ❑3.RENEWAL PERMIT fSpedly reason-for focal use only) {Speclly change-lar focal use only) SL a.TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAMEorDBA-Doing Business As) FACILITY ID N < _ 1 <br /> LOWION WITHIN SITE(O h' e9 431 C <br /> ` <br /> I.TANK DESCRIPTION <br /> TANK ID Nn /1 y� TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> II'Yee,complete one page for each compartment. <br /> DATE INSTALLED(YEARIMO) ( �J b TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only)- <br /> ' II.TANK CONTENTS <br /> TANK USE - 432 PETROLEUM TYPE <br /> ❑ 1, MOTOR VEHICLE FUEL ❑Is. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (N rrr~coop fete Pormiloum Type) ❑16. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NOWFUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3.CHEMICAL PRODUCT -COMMON NAME( CAS N(from HaZaACmps Materials lmmntory page) <br /> !rom Hazardous Materials lmm�tory page) <br /> ❑ 4. HAZARDOUS WASTE(fwWdes 11Used Oio <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL - ❑ 3.SINGLE WALL WITH ❑ 5, SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item orm ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑W. OTHER <br /> TANK MATERIAL-primary tank 0 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item OW ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑89. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-woondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ a. FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (Check one nem orwW ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99.OTHER Forkxa!use on <br /> one Nem onM <br /> OTHER CORROSION ❑ 1.MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN q34 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑89. OTHER (For foal use only) <br /> (Chad[one Item orWA ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Far lacal use a.W OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check aN that apply) 0 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBES ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> fV:LANK LEAK DETECTION <br /> IF SINGLE WALLTANK Check eN lhet s ): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one Nem on <br /> (31. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ I. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2- CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3, MANUAL MONITORING <br /> ❑ 4- STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ a. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBST CE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> 11go h✓ ga7ons ❑Yes ❑No <br /> CUPAFORM(4199) Formerly SWRCB Form B <br />