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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS =TANK PAGE 1 (two pages per tank) <br /> Page—of_ <br /> ARY <br /> URE <br /> TYPE OF ACTION ❑ I NEW SITE PERI'IIT ❑ 4 AMENDED PERMIT b(5 CHANGE OF INFORMATION O 7 PERMANENTLY E LOS E SITE <br /> (Check one item only) 430 <br /> ❑ 3 RENEW AL PERMIT (Specify reason-for local use only) (Specify reason-for local trsc only) ❑ <br /> 8 TANK REMOVED <br /> BUSINESS NAME(Same a6 FACILI�'YNA,�fE or�D,rBA-t�D.oing Business As) 3 <br /> FACILITY ID: <br /> (.NA C V`f��'/� 431 <br /> LOCATION WITHIN SITE(Optional) <br /> plot plan with the location of the UST system including buildings and landmarks shall be submitted to the Iocal agency.) <br /> I.TANK DESCRIPTIOt (A scaled <br /> TANK ID#. a3z COMPARTMENTALIZED TANK ❑Y No a34 <br /> TANK MANUFACTURER �. <br /> If-Yes-,complete one page for each compartment. <br /> A 437 <br /> 0SCS, lC S'1 � <br /> a36 NUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS <br /> 438 <br /> ADDITIONAL DESCRIPTION(For local�eonly) <br /> II.TANK CONTENTS <br /> 440 <br /> TANK USE 439 PETROLEUM TYPE <br /> MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED �❑22. LEADED ❑5. JET FUEL <br /> (If marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED �.�3. DIESEL ❑6. AVIATION FUEL <br /> ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED I ❑`4. GASOHOL ❑99.OTHER 442 <br /> ❑3. CHEMICAL PRODUCT COMMON NAME ((mm Hazardous Materials Inventory page) <br /> 4al CAS#(from Hazardous Materials Inventory Page) <br /> ❑4. HAZARDOUS WASTE <br /> (Includes Used Oil) <br /> ❑95.UNKNOWN <br /> III. TANK CONSTRUCTION <br /> EMATERIA <br /> K —01 SINGLE WALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> 443 <br /> EXTERIOR MEMBRANE LINER 095-UNKNOWN <br /> nly) <br /> DOUBLE WALL Q 4. SIGNLE WALL IN VAULT ❑99. OTHER <br /> FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 4u <br /> IAL-primary tank I. BARE STEEL �,�� <br /> ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ( .,,FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> nly) \.-� <br /> REINFORCED PLASTIC(FRP) <br /> RIAL-secondary tank I. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE <br /> 95. UNKNOWN 445 <br /> (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W FIBERGLASS 88. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) 0-loto•COATED STEEL <br /> III <br /> ❑5. CONCRETE t 447 <br /> r <br /> RIOR LINING 1.RUBBER LINED :3.EPDXY LINING 5.GLASS LINING 5.UNKNOWNaa6 DATEINSTALLEDG ❑2 ALKYD LINING ❑ HENOLIC LINING ❑6 UNLINED ❑99 O ER (For local use only) <br /> ERGLA <br /> only) I P DATEINSTALLED 449 <br /> ROSION ❑I MANUFACTURED CATHODIC ❑41�tPRESSED CURRENT ERGLASS CED PLASTIC ❑❑99 UNKNOWN <br /> HER <br /> PROTECTION IF APPLICABLE PROTECTION (For local use only) <br /> (Check one item only) ❑2 SACRIFICIAL ANODE 4S2 <br /> SPILL AND OVERFILL <br /> YEAR INSTALLED 450 TYPE(local use only) <br /> 451 OVERFILL PROTECTION EQ3cf4kEXE <br /> MFrNT:YEAR INSTALLED <br /> (Check all that apply) ❑1 SPILL CONTAINMENT ❑1 ALARMFILL TUBE SHUT OFF VALVE <br /> ❑2 BALL FLOAT MPT <br /> DROP TUBE <br /> `� <br /> ❑3 STRIKER PLATE <br /> IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) <br /> 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> IF SINGLE WALL TANK(Check all that apply) (Check one item only) <br /> C]1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ <br /> 6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORINIATION/PERMANENT CLOSURE IN PLACE 457 <br /> 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INER MATERIAL? <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) gallons ❑Yes No <br /> UPCF(12/99 revised) <br /> 10 Formerly SWRCB Form B <br />