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UNIFIED PROGRAM CONSOLIDATED FORR� N� k-TA KS <br /> II -TANK PAGE 1 �" � � <br /> Iii UNDERGROUND STORAGE TANKS <br /> (two pa tank) •,� <br /> Page of t-ty s <br /> ❑ 5.CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 7. PERMANENTLY CLOSED ON SIT <br /> (Check one item only) change•for local use only) ❑ 8. TANK REMOVED 430 <br /> ❑3.RENEWAL PERMIT (SpxM reason-I.I-.I use only) (Speufy 1 <br /> FACILITY <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> 10• <br /> LOCATION WITHIN SITE(Op6on30 <br /> a71 <br /> 1.TANK DESCRIPTION �es ❑ No <br /> TANK MANUFACTURER COMPARTMENTALIZED TANK <br /> II'Yei,complete one page for each compartment. <br /> TANK 10 0 / <br /> O ®[� & .S' NUMBER OF COMPA TMENTS <br /> o / TANK CAPACITY IN GALLONS <br /> DATE INSTAlLEO EARlMOI � <br /> ADDITIONAL OESCRI TION(Forlocal use only) <br /> it.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> nn/ ❑ 2. LEADED <br /> Ga"I MOTOR VEHICLE FUEL to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6. AVIATION FUEL <br /> (If marked,complete petroleum Type) ❑1b. PREMIUM UNLEADED ❑99. OTHER <br /> ❑ 2. NON-FUEL PETROLEUM 01s )„110GRADE UNLEADED ❑ 4. GASOHOL CAS 0(from Hazardous Materia/s Inventory page) <br /> ❑ 3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Matenals Inwnfory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Used OIQ <br /> 111.TANK CONSTRUCTION <br /> ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> TYPE OF TANK ❑ 11. SINGLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Check one Item Only) 12-2-DOUBLE WALL ❑ 4, SINGLE WALL IN A VAULT ❑gg OTHER <br /> C1 3. FIBERGLASS/PLASTIC C3 5. CONCRETE <br /> ❑95. UNKNOWN <br /> TANK MATERIAL•primary tank tank I. BARE STEEL <br /> _STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL <br /> C]99. O7HER�--- <br /> (Check one dem only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑95. UNKNOWN <br /> BARE STEEL ❑, 3. FIBERGLASS I PLASTIC ❑ 6. FRP COMPATIBLE W1100%METHANOL C199 OTHER <br /> TANK MATERIAL•secondary tank ❑ 1 <br /> LiS 4. STEEL CLAD WIFIBERGLASS ❑ S. FRP NON-CORRODIBLE JACKET <br /> (Check one item only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑10 COATED STEEL <br /> ❑ S. CONCRETE OATEINSTALLEO <br /> ❑ 3. EPDXY LINING C15. GLASS LINING ❑95. UNKNOWN433 <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED 11 6 UNLINED C]99. OTHER (Forfoca <br /> OR COATING C14. PHENOLIC LINING GATE INSTALLED <br /> ❑ 2. ALKYD LINING <br /> ❑95. UNKNOWN 474 <br /> (Check one item on ) 3. FIBERGLASS REINFORCED PLASTIC _ <br /> OTHER CORROSION C31. MANUFACTURED CATHODIC ❑gg. OTHER �- (For Iota <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For use onry) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> YEAR INSTALLED TYPE( 77 <br /> SPILL AND OVERFILL <br /> G�r1. ALARM ❑ 7. FILL TUBE SHUT OFF VALVE <br /> (Check all that apply) ❑ 1. SPILL CONTAINMENT_�- ❑ 4. EXEMPT <br /> ❑ 2. BALL FLOAT <br /> ❑ 2. DROP TUBE <br /> ❑ 3. STRIKER PLATE . <br /> N.TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK W17H BLADDER'Check one item onI): <br /> IF SINGLE WALL TANK Check all that ep ) ❑ 5 MANUAL TANK GAUGING(MTG) ❑, 1 VISUAL(SINGLE WALL IN VAULT ONLY) , <br /> ❑ 1• VISUAL(EXPOSED PORTION ONLY) 1i+1 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 8. VAOOSE ZONE <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 7. MANUAL MONITORING <br /> [1 7 GROUNDWATER <br /> ❑ 7. CONTINUOUS ATG C] 8. TANK TESTING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑99. OTHER <br /> BIENNIAL TANK TESTING <br /> V.TANK CLOSURE INFORMATION i PERMANENT CLOSURE 143 LAC TANK FILLED WITH INERT MATERIAL? <br /> R/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> ESTIMATED DATE LAST USED(Y geeons ❑Yes ❑NO <br /> Formerly SWRCB FC <br /> CUPAFORM(4199) <br /> I <br />