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UNIFIED PROGRAM CONSOLIDATED FORM U TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 1011' (two pages per tank) Page (_ of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑4.AMENDED PERMIT CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one Rem only ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify mason-forlocal use only (Specify change-forkieal use onW ❑ S. TANK REMOVED 430 B SS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID#. 1 G t'1� T�� LOCATION WITHIN SITE(Optio&O 431 l:TANK DESCRIPTION TANK ID# TANK MANUFACTURER - - O N COMPARTMENTALIZED TANK 11 for No `�rV If'Yes',complete one page for each co ant. DATE INSTALLED(YEAR/MO) - TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS R - U. 1 ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL (if marked,complete Petroleum Type) 11 1b. PREMIUM.UNLEADED ❑ 3. DIESEL 8.AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM - ❑tc. MIDGRADE UNLEADED ❑ 4. GASOHOL 0 99. OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) CAS#(hom Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(includes Used Oil) 0 95, UNKNOWN ill.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Rem only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 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 A4, STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1: BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95..UNKNOWN (Check one item only) 11 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 ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5.GLASS LINING ❑85. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER For local use only) (Check one item only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑89. OTHER (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE- - 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE � �... .., rr � � ,,�•-� , ..,�.. �., >...,lV'.�'t'AU•littiLE�1K'pE��kUk. _._. IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item on ): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ B. 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 [199. OTHER V.TANK'CLOSURE INFORMATION I 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 CUPAFORM(4/99) Formerly SWRCB Form B