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1 i UNIFIED PROGRAM CONSOLIDATED FORM /�� UNDERGROUND STORAGE TANKS -TANK PAGE 1 TANxs (two pages per tank) TYPEOFACIION �NEWSITEPERMIT ❑ 4 AMEIIDEDPERMTT �a---Ol- ❑ S CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Cluck of idem only) ❑ 7 PERMANENTLY CLASED ON SITE f ❑ 3 RENEWAL PERMIT (Specify mum-for�M only) (SpeNfy R&M far local aae oalY) ❑ 8 TANK REMOVED 430 BUS ESS.NAME(same as FAC1LTfY NAME o�DBA- �BwsjWm-uFACILITY ID; ^� / t LOCATION WITHIN SITE(OptioDa) .............. t�J2 J 431 (fo2r�Qt2 )I D - D - 1.TANK DESCRIPTION (A scaled plot plan with the location ofthe UST system including buildings and landmarks shall be submitted to the local aetmey.) TANK ID# 432 TANK /MANUFACTURE 433COMPARTMENTALIZED TANK Yes No 434 043 l/<s+ .r�oe:J.-►� if-Vag.compku am pale far pck ooh DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS4361 NUMBER OF COMPARTMENTS 437 L rO eq Y^A! ADDITIONAL DESCRIPTION(For ktul use only) 438 I IL TANK CONTENTS TANK USE 419 PETROLEUM TYPE ------------- 1. 1. MOTOR VEHICLEFUEL ❑ln. REGULAR UNLEADED 4a, ❑2. LEADED ❑S. JET FUEL (lf marked Templar Pwvlwrm Type) ❑ 16. PREMIUM UNLEADED ❑3. DIESEL [36. AVIATION FUEL NON-FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑4. GASOHOL OTHER 0./Z3. CHEMICAL PRODUCT 0./Z 4. NAME(6om Razw&.mmaj h lawnwy pale) µ) CAS#(Som Haardmu M.wriab Inwnuxy pa8e) 442 i ❑4. HAZARDOUS WASTE J (1ack.da Used OI]) ❑95.UNKNOWN JU. TANK CONSTRUCTION TYPE OF TANK SINGLE WALL 3. SINGLE WALL WITH S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chea ant tum only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-pdmuyum BARE STEEL 0 3. FIBERGLASS/PLASTIC 5. CONCRETE 95.UNKNOWN 444 (0teck one Nem Dory) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [38. FRP COMPTIBLE W1100°%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ! TANK MATERIAL-se000dary uak I. BARE STEEL 3. FIB F ERGLASS/PLASTIC US. CONCRETE U 95. UNKNOWN 44 (Check me item only) ❑2. STAINLESS STEEL ❑4.'STEEL CLAD W/FMERGLASS C)8. FRP COMPTIBLE W/IW%METHANOL ❑99.OTH R /!I REWFORCED PLASTIC(FRP) ❑10.COATED STEEL / ❑S. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 0 S.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING Q/1 UNLINED ❑99 OTHER {[luck one Ncm eoly) v\ (Few loaf use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER C/ (Cbeckotu kem only) ❑2 SACRIFICIAL ANODE (FCC local uae only) SPILL AND OVERFILL YEAR INSTALLED '430 TYPE(tow use ony) 431 OVERFILL PROTECTION EQIJIPMENT:YFAR INSTALLED 432 (Check dl dut apply) ❑1 SPILL CONTAINMENT ❑I ALARM C33 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE J/ [32 BALL FLOA7� � Cl4 EXEMPT ❑3 STRIKER PLATE �',/� : IV.TANK LEAK DETECTION(A doa*p o of the mmhoriag program alW l be aubmipsd m eke lord agency.) IF SINGLE WALL TANK{Chak d1 that appty) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 434 ❑1 VISUAL(EXPOSED PORTMTG ION ONLY) ❑3 MANUAL TANK GAUGING 1 one Item only) ( } 13❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING{ATG} ❑6 VADOSE ZONE' ❑2 CONTINUOUS INTERSTITIAL MONITORWG ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MAN(JAL•MOMToRWG ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE II ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED U TY OF SUBSTANCE REMAWING 456 TANK FILLED WITH INERT TERIAL? 437 gallons ❑Yes No t UPCF(12/99 revised) 10 Formerly SWRCB Form B