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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) 8. TEMPORARY SITE CLOSURE <br /> (Check one item only) <br /> ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify mason-for local use o*) (Specify charge-for local use only) ❑ S. TANK REMOVED 430 <br /> BUSINESS NAME(Some as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 <br /> LOCATION WITHIN SITE(Opbonso 431 <br /> 2 <br /> 1.TANK DESCRIPTION_ <br /> TANK ID# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No <br /> © _S^ U r If'Yes',complete one page for each compartment <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS(( NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (II marked,complete Petroleum Type) 1b. PREMIUM.UNLEADED - ❑ 3. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS#(11rom Hazardous Materials Inventory page) <br /> Used Oil) <br /> 95, UNKNOWN <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK 1191. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99, OTHER <br /> TANK MATERIAL-primary tank 1. BARE STEEL ❑ 3. FIBERGLASS/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 W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING 1:11. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED 1199. OTHER <br /> (Check one item only) (For local use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ q. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> -SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check a0ihat apply) ❑ 1 SPILL CONTAINMENT <br /> ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> TMpCL K <br /> IF SINGLE WALL TANK Check ail that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENTCLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons El No <br /> El Yes <br /> q, <br /> ?D <br /> CUPAFORM(4/99) • Formerly SWRCB Form B <br />