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V UNIFIED PROGRAM CONSOLIDATED FORM . �K UNDERGROUND STORAGE TANKS-TANK PAGE 1 TASI two pa as lank Page _ _ TYPE OF ACTION d.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one dem only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify reason-for bealuse ordy) (Specify change-for local use only) ❑ 8, TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA- 'ng Business As) FACUJTY 1D# 1 Q!! ve 7 Iloilo I I I I I LOIATITI�OON WITHIN SITE(OpfionaO 431 I.TANK DESCRIPTIo_ TANK ID# TANK MANUFACTURER , COMPARTMENTALIZED TANK Yes ❑ No _/ If"Yes',complete one page for each companment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS S �-i`T (?-)C- q 2 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS TANK USE - 432 / PETROLEUM TYPE 1. MOTOR VEHICLE FUEL Ur/1a. REGULAR UNLEADED ❑ 2. LEADED Cl 5. JET FUEL (If marked,complete Petroleum Type) 01b. PREMIUM.UNLEADED - ❑ 3. DIESEL ❑ 6. AVIATIONFUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(from Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) Used Oil) 95, UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK ❑ 1. SIN LE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one Rem only) DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN 114. SINGLE WALL IN A VAULT ❑98 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ IBERGLASS/PLASTIC 115. CONCRETE 1195. UNKNOWN (Check one item only) 112, STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3 FIBERGLASS/PLASTIC �❑. & FRP COMPATIBLE W/100%METHANOL 1195. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL 5-4. STEEL CLAD W/FIBERGLASS 1�9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING DATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. SS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING 114. PHENOLIC LINING 8. UNLINED ❑99. OTHER (Check one Rem on ) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION (Check one item only) 114. IMPRESSED CURRENT ❑99. OTHER ❑ 2. SACRIFICIAL ANODE (For local use only) -SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE El-T. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IY=TANK LEAK[t1wTE.Cim, IF SINGLE WALL TANK Check all that a IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VAOOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/IPERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallon 1:1 Yes ❑No O Ulu CUPAFORM(4/99) • �� Formerly SWRCB Form B