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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify mason-for local use only) (Specify change-for local use only) ❑ 8.TANK REMOVED 430 <br /> BUSINESS NA (Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN 1 <br /> A <br /> LOCATION WITHIN SITE(Opdonaq 431 <br /> 1.TANK DESCRIPTION <br /> TANK to# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> TD7'� If'Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL C1ta. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (If marked,complete petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> C32. NON-FUEL PETROLEUM C1tc. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT CAS#(from Hazardous Matedals Inventory page) <br /> COMMON NAME(from Hazardous Materials Inventory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Used 00 <br /> 95 "KNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALLEXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED El 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER (For local use only) <br /> (Check one item only) <br /> DATE INSTALLED <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local use only) <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ I. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.,TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check alf that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ S. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99_ OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form 8 <br />