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UNIFIED PROGRAM CONSOLIDATED FORM yY1 TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of TYPE OF ACTION NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item onty) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spey mason-for local use only) (Specify change-for local use only) ❑ S. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN 1 LOCATION WITHIN SITE(Oplionaq 431 1.TANK DESCRIPTION TANK to N TANK MANUFACTURER COMPARTMENTALIZED TANK P Yes ❑ No If'Yei,complete one page for each compartment. Joor DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS q-1-0o i 100 2 ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE UU/1'1. MOTOR VEHICLE FUEL la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (It marked,complete Petroleum Type) ❑1b PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCTCAS N(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous M rials Inventory pag) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) El 95 UNKNOWN I II ANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 3. LE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM TERIOR MEMBRANE LINER ❑95. UNKNOWN (Check one item only) . DOUBLE WALL 4. SINGLE WALL IN A VAULT ❑yq OTHER TANK MATERIAL•primary tank 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC �❑/'8. FRP COMPATIBLE WI100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS 1Q 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING DATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING V8. UNLINED ❑99. OTHER (For local use only) (Check one item on ) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3, FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 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 local use onty) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all that apply) �I( 1. SPILL CONTAINMENT ❑ 1. ALARM 7,3, FILL TUBE SHUT OFF VALVE �2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT X3. STRIKER PLATE560.J N,TANK LEAK DETECTION IF SINGLE WALL TANK Check all that a ): 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) ❑ S. VADOSE ZONE CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUSATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANK TESTING BIENNIAL TANK TESTING - 099, OTHER V.TANK CLOSURE INFORMATION)PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No o0 -3 T�oS/5.5.3CP CUPAFORM(4/99) • . Formerly SWRCB Form B c, � t1310