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UNIFIED PROGRAM CONSOLIDATED TA KS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two es e Ill Page _ ❑ 5.CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 7, PERMANENTLY CLOSED ON SITE I V (Check one item only) ❑ B. TANK REMOVED 430 RENEWAL PERMIT (S �/y mason-!or local use only) (Specie/change-for local use only) 1 FACILITY ID N BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) C E" /C 14.11,C11 LOCATION WITHIN SITE(OptionSO a31 IJ L 1.TANK DESCRIPTION Q'Yes ❑ No TANK MANUFACTURER COMPARTMENTALIZED TANK r"' If'Yes',complete one page for each compartment. TANK 10 N Y d:/_6 ., �' O-60,6-a.�� NUMBER F COMPA N75 DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS ADDITIONAL DESCRIPTION(FOrlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 5 JET FUEL ❑1. REGULAR UNLEADED ❑ 2. LEADED LI 1. MOTOR VEHICLE FUEL ❑ 3. DIESEL ❑ 6. AVIATION FUEL -- (If marked,complete Fbtroleum Type) ❑1b PREMIUM UNLEADED ❑99. OTHER ❑ 4. GASOHOL ❑ 2. NON-FUEL PETROLEUM tc MIDGRADE UNLEADED CAS N(from Hazardous Materials Inventory page) ❑ 3. CHEMICAL PRODUCT COMMON NAME(!mm Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Orq 111.TANK CONSTRUCTION ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM TYPE OF TANK ❑ y SINGLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) 2. DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT ❑gg_ OTHER ❑ 1. BARE STEEL ❑ 3. FIBERGLASS 1 PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN TANK MATERIAL-primary tank ❑99. OTHERS-- PY�5TEELCLAD WlFIBERGLASS ❑ 6. FRP COMPATIBLE W/f00°�METHANOL (Check one item only) ❑ 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) ❑95. UNKNOWN ❑ 3. FIBERGLASS I PLASTIC ❑ 6. FRP COMPATIBLE WI100°h METHANOL TANK MATERIAL-secondary lank ❑ t. BARE STEEL may/ ❑99. OTHER�- (Check one item only) ❑ 2. STAINLESS STEEL !7 ,- STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE OATEINSTALLED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 6 UNLINED ❑99. OTHER (For locaj use poly) OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING DATE INSTALLED 434 (Check one item On _ ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN OTHER CORROSION ❑99. OTHER (Forloca PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT (Check one item only) ❑ 2. SACRIFICIAL ANOO YE (For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED YEAR INSTALLED TYP SPILL AND OVERFILL �,/ 7 ❑ 3. FILL TUBE SHUT OFF VALVE (1+l 1. ALARM (Check all that apply) ❑ 1. SPILL CONTAINMENT C1 4. EXEMPT ❑ 2. BALL FLOAT ❑ 2. DROP TUBE ❑ 3. STRIKER PLATE IV.TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER(CAeck one item onl): IF SINGLE WALL TANK Check all that a ) ❑ 5_ MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) . ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ 6 VADOSE ZONE 2-T CONTINUOUS INTERSTITIAL MONITORING ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ T GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) a B. STING 99 OTHER BIENNIAL TANK TESTING V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE 14PLACE TANK FILLED WITH INERT MATERIAL? IMATED DATE LAST USED(PRIMO/DAY) ESTESTIMATED QUANTITY OF SUBSTANCE REMAINING gallons ❑Yes ❑No Formerly SWRCB Fc CUPAFORM(4/99)