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i ' <br /> Ah <br /> e 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 CRI' <br /> NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify meson-for local use OW (Spit*change.for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same ss FACILITY NAME or DBA-Doing 3usiness As) FACILITY ID k 1 <br /> r A <br /> LOCATION WITHIN SITE(Oplionsq 431 <br /> I.TANK DESCRIPTION <br /> TAN;TIONAL <br /> TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes Cl No <br /> I('Yes',Complete one page for each compartment <br /> DATEDESCRIPTION <br /> TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDIlocal use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432PETROLEUM TYPE <br /> 1 MOTOR VEHICLE FUEL (a REGULAR UNLEADED ❑ 2. LEADED ❑ 5 JET FUEL <br /> (ll marked,complete Petroleum Type) ❑ib PREMIUM UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION FUEL <br /> ❑ 2. NOWFUEL PETROLEUM ❑le. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99 OTHER <br /> ❑ 3 CHEMICAL PRODUCT CAS a(fmm Nazanious Materials Ineenfory page) <br /> COMMON NAME(from Hazardous Materials Inventory page) <br /> ❑ 4 HAZARDOUS WASTE(Includes <br /> Used 0,0 <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1 SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5 SINGLE WALL WITH INTERNAL BLADDER 3YSTElA <br /> (Check one item only) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95 UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL•primary tank ❑ 1. BARE STEEL FIBERGLASS I PLASTIC ❑ 5 CONCRETE ❑95 UNKNOWN <br /> (Check one dem only) ❑ 2_ STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 6 FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ t BARE STEEL 3. FIBERGLASS l PLASTIC ❑ 8. FRP COMPATIBLE W/100°%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 /> ❑ S. CONCRETE <br /> TANK INTERIOR LINING DATE INSTALL D <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING 5 GLASS LINING ❑95 UNKNOWN4 3 f <br /> ® (for local use o <br /> 2-4 00 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8 UNLINED 99. OTHER P! <br /> (Check one Remo DATE INSTALLED <br /> OTHER CORROSION [] 1 MANUFACTURED CATHODIC 3. 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 YINALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check a81Raf apply) ��1. SPILL CONTAINMENT p _ ❑ 1. ALARM 3 FILL TUBE SHUT OFF VALVE <br /> W 2. DROP TUBE r 's C ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Aeek as(haft IF DOUBLE WALL TANK OR TANK WITH BLADDER heck one item on <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 8. MANUAL TANK GAUGING(MTI) 0[ s.yYMUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE IONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATO ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ & TANK TESTING <br /> BIENNIAL TANK TESTING ❑gg. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED OUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> 1 <br /> CUPAFORM(4/99) ® Formerly SWRCB Form 8 <br />