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NIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 /0�� <br /> lob pages par <br /> �// Page _ o <br /> L7 <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 /> ❑3.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Specify reason-for local use only) (Specify change-for local use only) ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Some as FACILITY NAME or DBA-Doing Business As) FACILITY 10 N 1 <br /> I, 1 <br /> LOCATION WITHIN S (Opfionap 431 \ <br /> 1..TANK DESCRIPTION <br /> TANK ID# TANK <br /> {MANUFACTURER COMPARTMENTALIZED TANK es ❑ No <br /> Ir"Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) _ TANK CAPACITY IN GA NS NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> II.TANK CONTENTS <br /> -MOTOR <br /> USE 432 PETROLEUM TYPE <br /> ET-1 <br /> . VEHICLE FUEL ❑1a. ULAR UNLEADED n 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) 1b. PREMIUM UNLEADED 133. DIESEL ❑ 6. AVIATION FUEL <br /> 02. <br /> 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(hom Hazardous Materials Inventory page) CAS#(hom Hazardous Materials Inventory page) <br /> Used Oil) <br /> 0 95, UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑, 1/.�1N�LE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) L7 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL-primary tank ❑ 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 6 4. STEEL CLAD W/FIBERGLASS ❑ B. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC �❑, 8/Fgp 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 DATE INSTALLED <br /> OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑❑ 5G6AW LINING ❑95. UNKNOWN433 <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING L7/8. 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 PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) 112. SACRIFICIAL ANODE (For local use only) <br /> -SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlecal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT <br /> I e ❑ 1.ALARM -113. FILL TUBE SHUT OFF VALVE <br /> BB"272. DROP TUBE W ' ` ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> .' EPSOM <br /> IF SINGLE WALL TANK(Check all that appy: 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) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 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 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> f ❑Yes ❑No <br /> Del <br /> CUPAFORM(4/99) . • Formerly SWRCB Form B <br />