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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 C]4. AMENDED PERMIT ®5. CHANGE OF INFORMATION) [16. TEMPORARY SITE CLOSURE (Check one item only) ❑7. PERMANENTLY CLOSED ON SITE ❑3. RENEWAL PERMIT [:]8. TANK REMOVED 430 (Specify reason-for local use only) (Specify change-for local use only) BUSINESS NAME(Same as FACILITY NAME or DBA- ing Business As) 3 I FACILITY ID It 1 TTJ I COriOCOphillipS# �sq/7 LOCATION WITHIN SITE(Optional) / 431 I.TANK DESC IPTION (A scaled plot plan with the location ojthe UST systern including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANKACTURER 433 COMPARTMENTALIZED TANK ElYes a No 434 If OYesO,complete one page for each part t. DATE INSTALLED(YEAR/MO) 435 TANK CAPACI/TY IN GALLONS ®V 436 NUMBER OF COMPARTMENTS 437 19 ft/-7l 00 eq ADDITIONAL DE9CRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL �16-,ked.complete Petroleum Type) Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventorypage) 441 CAS H(from Hazardous Materials Inventory page) 442 Used Oil) ❑95. XERXES III.TANK CONSTRUCTION TYPE OF TANK ❑ SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) DOUBLE WALL EXTERIOR MEMBRANE LINER 095. XERXES ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL,-prunary tank BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. XERXES 444 (Check one item only) 02. STAINLESS STEEL ❑4. STEEL CLAD W/PIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑8. FRP COMPATIBLE W/100%METHANOL ❑95. XERXES 445 (Cheek one item only) [:]2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS [:]9. FRP NON-CORRODIBLE JACKET [:199. OTHER REINFORCED PLASTIC(FRP) []10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑3. EPDXY LINING - ❑5. GLASS LINING ❑95. XERXES 446 DATE INSTALLED 447 OR COATING 02 ALKYD LINING 04. PHENOLIC LINING . UNLINED 099. OTHER Check one item only) 11 For local use only) OTHER CORROSION ❑1. MANUFACTURED IMFIBERGLASS REINFORCED PLASTIC ❑95. XERXES 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC ❑4. IMPRESSED CURRENT ❑99. OTHER (Check one item only) PROTECTION (For local use only) ❑2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INST 450 TYPE(For local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) SPILL CONTAINMENT ❑1. ALARM FILL TUBE SHUT OFF VALVE DROPTUBE ❑2. BALLFLOAT E]4. EXEMPT STRIKER PLATE IV. TANK LEAK DETECTION (A description ojthe monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply):. _ 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 ❑I, VISUAL(EXPOSED PORTION ONLY) 05. MANUAL TANK GAUGING(MTG) ❑1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6. VADOSE ZONE 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) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 Rallons ❑Yes ❑No UPCF(1/99 revised) Formerly SWRCB Form B