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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ld/5. CHANGE OF INFORMATION) 1'J,,L`� ❑C18. TEMPORARY SITE CLOSURE (Check one item only) 1 1 c DYIStle c G(o-7c(„T. ❑3.RENEWAL PERMIT �� I I 7. PERMANENTLY CLOSED ON SITE (Specify reason-for local use orgy) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 Q' BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 4Yea Gv �v LOCATION WITHIN SITE(Optional) 431 I.TANK DESCRIPTION TANK ID# TANK MANUFACTURER a COMPARTMENTALIZED TANK ❑ Yes ❑ No .3 s C^ 11"Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS 1 1200-0 ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL (If marked,complete Petroleum Type) �. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM Mlllc MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICALPRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(hom Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) Used Oil) El 95, UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) r11 r DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN V� ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS M-f FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC Ef& FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2, STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING DATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING El 4. PHENOLIC LINING 6. UNLINED ❑99. OTHER (Check one item only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC El 95 UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) 1. SPILL CONTAINMENT ��1 ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE 6Y2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No DJDW a,., I.- CUPAFORM(4199) Formerly SWRCB Form B