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NIFIED PROGRAM CONSOLIDATED FORM <br /> TANO <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one dem only) <br /> ❑3.RENEWAL PERMIT ❑ . PERMANENTLY CLOSED ON SITE <br /> (Specify reason-forlocal use only) (Specify change-for local use only) 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NYAE or DBA-Doing Business As) 'FACILITY ID#.._ 1 <br /> i <br /> LOCATION WITHIN SITE(O 431 <br /> M_Zzz <br /> 1.TANK DESCRIPTION <br /> TANK TANK MANUFACTURER <br /> (//V/ACTURE COMPARTMENTALIZED TANK ❑ Yes No <br /> If'Ves-,complete one page for each w artment. <br /> DATE INSTALLED(YYR/MO) TANK CAPACITY IN GALS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only)- <br /> 11.TANK CONTENTS" <br /> TANK USE - 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5.JETFUEL <br /> (If marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. IATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRADE UNLEADED ❑ 4. GASOHOL OTHER L/ <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(hom Hazardous Materials Inventory page) CAS#ilmm Hazardous Materials Inventory page) <br /> Used 010 <br /> 1195. UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1, SINGLE WALL - ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUB WALL EXTERIOR MEMBRANE LINER ❑g5. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary tank 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondarytank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL 1195. UNKNOWN <br /> (Check one demonly) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LININ ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER <br /> (Check one item on ) (For local use only) <br /> OTHER CION IF ON DATE INSTALLED <br /> PROTEOTHERCTION�I S ON BLE ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one i ❑ 2. SACRIFICIAL ANODE (For local use only <br /> -SPILL AND OVERFILL - YEAR INSTALLED TYPE(For kcal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check ad that apply ❑ 1 SPILL CONTAINMENT <br /> �. ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IF SINGLE WALL TANK Check all that a IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> 1199. OTHER <br /> V.TANK CLOSURE INFORMATION'I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DAT LAST LAV(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MAAT�ER/IAgallonsYes <br /> CUPAFORM(4/99) O�1�" 'Yq Formerly SWRCB Form B <br />