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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 ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ G. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify mason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME r DBA-Doing Business As FACILITY ID# N111 1 �•rc: LOCATION WITHIN SITE(Op na0 1 t *0 I.TANK DESCRIPTION TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ENO ®_ r If'Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS /19l ADDITIONAL DESCRIPTION(For local use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL L 1a,,REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) 'i o. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL 112. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS#(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 95, UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL GK3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL 114. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE Wi100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ® ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2.ALKYD LINING - ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER (For local use only) (Check one item only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For focal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check aft that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROP TUBE it ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE 1Q IF SINGLE WALL TANK(Check aN that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. 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 099, OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRNdOIDAY) ESTIMATED QUANTITY OF SUPcTnurE REMAINING 435 TANK FILLED WITH INERT MATERIAL? - gallons ❑Yes ❑No ' 1 CUPAFORM(4/99) Formerly SWRCB Form B