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r <br /> NIFIED PROGRAM CONSOLIDATED FORM <br /> TANK <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 f <br /> (Check one item only) 1` <br /> ❑ 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-/orloee/use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN 1 <br /> t 3� <br /> LOCATION WITHIN SITE(Optionsq / 431 RA <br /> c5o <br /> 7.TANK DESCRIPTION <br /> TANK IDN TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK Yes CNo <br /> 1 <br /> ►�.///1 r-//1 xv If'Yes°,complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) - TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. <br /> OR VEHICLE FUEL 1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (if 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 N(from Hazardous Materials Inventory page) <br /> Used Oil) <br /> 95, UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. LE 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 1:195. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 1:14. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> EINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 913. FIBERGLASS/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 /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING <br /> ❑ 1. RUBBER LINED 113. EPDXY LINING 5. GLASS LINING 1195. UNKNOWN433 GATE INSTALLED <br /> OR COATING .. <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER <br /> (Check one item on ) (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 ❑ 4. 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 all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> DETRC:311N <br /> IF SINGLE WALL TANK Check all that a 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) ❑ B. 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/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITHINERT MATERIAL? <br /> gallons <br /> El ❑No <br /> �� -G <br /> CUPAFORM(4/99) �`' • Formerly SWRCB Form B <br />