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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of _ TYPE OF ACTION YJ`7.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check ons 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 or DBA-CDoing Business As) FACILITY IDA t RaimIr�C J v LOCATION WITHIN SITE(Optional 431 adffiw- I.TANK DESCRIPTION TANK 10 A TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No .J DO 1 If*Yes*,complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS o 2 ADDITIONAL DESCRIPTION(Forlocal use only) U.TANK CONTENTS TANK USE 432 PETROLEUM TYPE �.t. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5, JET FUEL (if marked,complete Petroleum Type) ',tb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER j ❑ 3. CHEMICAL PRODUCTCAS A(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil 13 95 UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL R3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item Doty) _DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑gg_ OTHER TANK MATERIAL-primary tank IX 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check aro dem only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%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 WIFIBERGLASS X9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LININGDATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING X8. UNLINED ❑99. OTHER (For We/use only) (Check one item on ) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC [395. 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 only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED (Check all that apply) n7+1. SPILL CONTAINMENT /] /�{� ❑ 1. ALARM X3 FILL TUBE SHUT OFF VALVE 92. DROP TUBE 2�1 000 ❑ 2. BALL FLOAT ❑ 4. EXEMPT 163. STRIKER PLATE 2000 N.TANK LEAK DETECTION IF SINGLE WALL TANK Check aAtha�a ): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 02. CONTINUOUS INTERSTITIAL MONITORING ' ❑ 3. CONTINUOUSATG - ❑ 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) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No rA-0012-q3-7 T� 05r 5537 J • • Formed SWRCB Form B CUPAFORM(4/99)