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07/25/2005 15:07 2094633 EHD PAGE 02 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (two pages per tank) <br /> Page of <br /> r TYPE OF ACTION ❑I NEW SITE PERMIT ff, A.MtNDED PERMIT ❑ S CHANGE OF TNFOILMATION ❑ 6 TENIpoR.ARI'SITE CLOSURE <br /> ❑ 7 PERMANENTLY CLOSED ON SITE <br /> (CTeck ant;item only) <br /> a)0 <br /> ❑ 3 RENEWAL PERMIT (Specify rt:,:on-lorla.lweonly) (Spc<iryreason-lorloealttuoalyl ❑ 8 TANKRE\LOVED <br /> BUSINESS NAME(Samea.FAc U-IJYNA.%t9or DBA-Doi 616-int>.Ai) FACILITY ID: -_=- <br /> P OI <br /> 7 <br /> LOCATION WIT1iIN SITE io ) w <br /> i 330 �, 151a-151a- vr� G� q6J <br /> L TANK DESCRIPTION A scaled plot plan with the Dalton of the UST Aystern iocludinj buildings and Ivkmarks!hall be Submitted to the localency.) <br /> TANK 10!: �rTANK MANUFACTURER 7 \� 43) COMPARTMENTALIZED TANK Yes No 43+ <br /> 1(-Yn.complete Doe page far each somputmem, <br /> DATE INSTALLED(YEAMO) .U5 TANK CAPACITY IN C3 ONS A6 NUMBER OF C MPARTMENTS 413 <br /> R/ <br /> ADDITIONAL DESCRIPTION(Pot mcal tno or•ly) <br /> 11.TANK CONTENTS <br /> K USE 419 PETROLEUM TYPE 440 <br /> I. MOTOR VEuICLE FUEL ej-'J.. REGULAR UNLEADED ❑2. LEADED ❑5. rET FUEL <br /> (Ifmarkedcomplctc Feoolcum Type) Ib. PREMIUM UNLEADED ❑3. DIESEL '0 6.AVIATION FUEL <br /> D 2. NONTUEL PETROLEUM Q Ic. MIDCRADE V*ILEADED ❑4• GASOHOL D 99.OTHER o+2 <br /> 441CASH(kom Hatazdotte Mareriab In.enWry pane) <br /> [33.CHEMICAL PRODUCT COMMON NAME (kom Hazardotto hlalarialr lnveptory poli) <br /> ❑4. HAZARDOUS WASTE <br /> (Includes Uad Oil) <br /> ❑95.VN KNOWN <br /> 111.'7AtNK CONSTRUCTION <br /> TYPE OF TANK <br /> L SINGLE WALL U 3. SINGLE WALL WITH UJ S.SMGLE WALL WITH fNTEKNA.L BLADDER SYSTEM +d1 <br /> (CTak one item only) EXTERIOR MEMBRANE LINER 095.UNKNOWN <br /> 21 DOUBLE WALL ❑4.SIGNLE WALL IN VAULT O 99. OTHER <br /> - leTANK MATERIAL•primary tarda 1. BARE STEEL 3. FIBERGLASS/PLASTI S.CONCRETE <br /> 95. UNKNOWN 4u <br /> (Chce4 one ilemonly) O 2. STAINLESS STEEL ❑4• STEEL CLAD W/FIBERGLA$S ❑!.FRP COMPTIBLE W/IODNe METHANOL CI 99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANKMATERIAL-rceondaryU.k 1. BARE STEEL FIBERGLASS)PLASTIC 3. CONCRETE <br /> 9S. UNKNOWN u1 <br /> (Clteclt ano itcm only) ❑2. STAINLESS STEEL O 4. STEEL CLAD W/FIBERCLASS ❑9. FRP COMPTIBLE W110OV,METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) d 10.COATED STEEL <br /> O S.CONCRETE <br /> TANK INTERJOR LMrr.G 1.RUBBER LINED 3.EPDXY LINING 5.CLASS LINING 0 93.UNKNOWN <br /> +16 DATEINSTALLT•D w3 <br /> OR COATING D 2 ALKYD LhINO CI a PHENOLIC LINING ❑6 UNLINED ❑99 OT HER ItA�Ar_, (oo,1-1,.ae only) <br /> (Chuck one hem only) <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC 3 FIBERGLASS REINFORCED PLASTIC ❑9S UNKNOkVN <br /> A4 DATEINSTACLEad <br /> D <br /> O 99 OTHER <br /> PROTECTION IF APPLICABLE PROTECTION ❑4I.(PRESSED CURRENT (For local uxady) <br /> (Check one item Daly) ❑2 SACRIFICIAL ANODE aS2 <br /> SPILL AND OVERFIL�L� YEARMSTALLED 439 TYPE(localuatanlr) SSI OVERFILL PROTECTIONEQNPMENT:YEARINSTALLED <br /> (Check all Wt apply) Ct�I PILL CONTAINMENT []FARM ❑3 FILL TUBE SHUT OFF VALVE <br /> DROP TUBE BALL FLOAT O 4 EXEMPT <br /> e STRIKER PLATE <br /> 1V.TANK LEAK DETECTION(A deoenphon of tl:emonitarin:Program rh311 bo wbm ned to Ne lord aacnoy.) <br /> IF SINGLE WALL TANK(CTeek all tbatapply) 463 IF DOUBLE WALL TANK OR TANK WITH BLADDER <br /> Klink m itant ardy) <br /> [31 VISUAL(EXPOSED PORTION ONLY) ❑$MANUALTANK GAUGING(MTG) 'O I VISUAL(SINGLE WALL M VAULT ONLY) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) D 6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING <br /> D 3 CONTINUOUS ATG ❑7 GROUNDWATER [33 MANUAL MONITORING <br /> ❑♦STATISTICAL rNVENTORY RECONCILIATION O&TANK TESTING <br /> (SIR) BIENNIAL TANK TESTING ❑99 OTHER <br /> IV.TANK CLOSURE INFORMATION/PERMA.NEN-F CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/bd0/DAY) ass EsnMATE0 QUANTITY OF SUBSTANCE REMAINING 06 TAMC FILLED WITH INERT MATERIAL. <br /> a57 <br /> gallons ❑Ycs ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form S <br />