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UNIFIEWROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 Page - of YPE OF ACT10N ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PER).!IT ❑ 5. CHANGE OF INFORMATION) Cl 6. TEMPORARY SITE CLOSURE n(r1c ora kem a%Yj . PERMANENTLY CLOSED ON SITE ❑ 1, RENEWAL PERMIT - �❑.,/j (SpeciffMason -Axbcwuse wyj (Speotychange -brbrawuse any) Val TANK REMOVED t1C BUSINESS NAME (Same as F4CILITY NAME or DBA DoirgOusiressAs) ) 5^z#: - :: `Y.,y'y': 3;•`.""<>•<-":.�.; T LlJ I �tA(•^" �..3 FACIlITY1D;: �� E:i:'•• s z s t � y WNLOCATION WITHIN SITE (OpDona/J 431 9 EE ac'�� , � YYtiT ...(. TANK DESCRIPTION (a2eledpatptans.�rs bca5cr,dmeusTiysterisuxh.�4pDukfipsefG4ndma;.*:iz f�DatuD(ruCsdMCsebulegency) ,VIK 10 1U2 T�,AHt`K�`MA2N=ACTURE®R' ' t11 I COMPARTMENTALIZED TANK 11 Yes ❑ No CU l.•.T N y1m ® Lj N If -Yet. oomptets one page for each msnpanment INSTALLED,fEARR.IO) U 0WP (For kW use orhy) r LJ WATERv` - primary taro --❑ t. 'BARE STEEL -----❑ II. TANK CONTENTS ... . TANK USE -_-- 439PETROLELR4 TYPE 44C %MOTOR VEHICLE FUEL 1a REGULAR UNLEADED 0 2. LEADED ❑ S. JET FUEL !.marked, comyete Pehyeum Type) i ❑1D PREMIUM UNlEACED ❑ 1. DIESEL ❑ 6. AVIATIONFUEL J 2. NON -FUEL PETROLEUM i ❑ tc MIOGRADE UNLF.'DED ❑ 4. GASOHOL ❑ 99. OTHER 3 CHEMICAL PRODUCT REINFORCED PLASTIC (FRP) (ISO COATED STEEL i ...i COMMON tLLt1E (ho^ t'.a:ulcus Ma'e�is Irnenbr/ pagej tit I CAS a (from Ha.a.•dous Materials ;mento ypage) 422 4 F;LARDOUS YJASTE (frc'hde: ❑ 3. EPDXY LINLYG Cl "5. 5 GLASS LINING UNKNOWN 446 DATE INSTALLED 447 Used 0.� Cl 2. ALKYO LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER :neat one kem orsyl 111. TA`OCCONSTRUCTION (For ball Ise orlM --c Or-TANt;r�'! Str: 5lE Ydar' ❑ 3. SINGLE YIALL WTIH ❑ 5 SLN�LE WALL WITH INTERNA,_ BLADDER SYSTEM 443 c. c aem -;Y% Cl 2 OOJ3LE WALL EXT1MOR MEMBRANE LINER V. UNKNOV.N !Cnerh one kem only) ❑ 2. SACRIFICIAL ANODE ❑ 4. SINGLE YMI. IN A VAULT ❑ 99. OTHER WATERv` - primary taro --❑ t. 'BARE STEEL -----❑ 1. FIBERGLASS I PLASTIC ❑ S. CONCRETEall's. VNKNOVN .. - :k ore item arty) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WtFIBERGLASS ❑ 8 FRP COMPATIBLE W 10aA METHANOL ❑ 99. OTHER,- _-__ REINFORCED PLASTIC (FRP) =;: < MATERIAL -sec ay lank ❑ I BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ B. FRP COMPATIBLE Y81=1 METHANOL ❑ 95. UNKNOWN t,5 .r!�k one fern oor/) Cl 2 STA3NLESS STEEL ❑ 4. STEEL CLAD YUFI8ERGLASS ❑ 9. FRP NONCORROOOLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) (ISO COATED STEEL ❑ S. CONCR="TE _ ?=NK LYTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINLYG Cl "5. 5 GLASS LINING UNKNOWN 446 DATE INSTALLED 447 :?.'. COATING Cl 2. ALKYO LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑ 99. OTHER :neat one kem orsyl (For ball Ise orlM O CORROSION El I. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC O 95. UNKNOWN ,448 DATE INSTALLED 44S 'POTECTK)N IF APPLICABLE OTE PROTECTION ❑ 4 iAPR_SSEO CURRENT ❑ 99. OTHER !Cnerh one kem only) ❑ 2. SACRIFICIAL ANODE (Farbeaf m omtA SPtLL AND OVERFILL YEAR INSTALLED 450 ME (Fcrbcal use oryyj 451 ' OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED' s i Check as that appy) Cl I SPILL CONTAINMENT ❑ 1. ALARM ❑ A FILL TUBE SHUT OFF VALVE ; ❑ 2. DROP TUBE I ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. 5TR)Y'a R PLATE fv:-TANK LEAK DETECTIONsa .':(AdefP-ofineaorvtoagptflrareShar Deuomttedbthehcatagencyj:. ;'k:'�::z% IF SINGLE WALL TANK (Check at mat appy: 4S3 j IF DOUBLE WALL TANK OR TANK WRTN BLADDER (Chet* one kem. orYyj- 454 - t. VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) i' ❑ 1- VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 .UTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE I Cl 2. CONTINU<WS w.ERSTTTTAL MONrTORING ❑ 1. CONTINUOUS ATC ❑ 7. GROUNDWATER ❑ 3. MANUAL. MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) • ❑ 6. T-ANKTESTING BIENNIAL TANK TESTING ❑ 99 OTHER , V. TA`IK CLOSURE LYFORMAT(ON7PERMANENT CLOSURE IN PLACE .. r r ESTIMATED DATE LAST USE�D�(rY�R`/MQl10AY) 455 ESTIMATED OUgA�NrrrYY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? tS.' 2�N KiJ Ow N y�lti6� .lis d/ 1 �J oalto ss j�Q ,q vol 0 ❑ Yes ❑ No a _P. JPCF (1/99 revised) 6 Formerty SWRCB Form B