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go Am UNIFIED PROGRAM CONSOLIDATED FO M TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages par tank) t Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT pQ r5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE ❑3.RENEWAL PERMIT (Check one item only) ✓✓✓✓✓�� ❑ 7. PERMANENTLY CLOSED ON (Specify mason-/or local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID/ - 1 LOCATION WITHIN SITE(Opaonao 431 I.TANK DESCRIPTION TANK ID# ECAPACITY URER COMPARTMENTALIZED TANK ❑ Yes No Fi (j 3 C� , \//J a ) If"Yes',complete one page for each co artment. DATE INSTALLED(YEAR/MO) N GALLONS NUMBER OF COMPARTMENTS vp � ADDITIONAL DESCRIPTION(Forlocal use only) II.TANK CONTENTS �,/ TANK USE 432 PETROLEUM TYPE �!"5�1. MOTOR VEHICLE FUEL REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (1/�ynked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED - ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(hom Hazardous Materials Inventory page) CAS N(from Hazardous Materials Inventory page) Used Olo 0 95, UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑❑/1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) �2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 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 W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%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 UNLINED ❑99. OTHER (Check one dem only) El (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ q. IMPRESSED CURRENT ❑99. OTHER (Check one item only) ❑ 2. SACRIFICIAL AN, I (For local use only) SPILL AND OVERFILL / YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED ) C� (Check all that apply) ❑ 1 SPILL CONTAINMENT / r ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OF'F VALVE ❑ 2. DROPTUBE � ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE T'ANKtEAK RETEC IF SINGLE WALL TANK Check all 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 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 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 U D(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons 11 No 11 Yes CUPAFORM(4/99) • l " (A A Formerly SWRCB Form B