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NIFIED 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) S. 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) ❑ S. TANK REMOVED 430 <br /> BUSINESS NAM (Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID N e� 1 <br /> Qls6j")� , U <br /> LOCATION WITHIN SITE(Op#onaO 431 <br /> tq I <br /> I.TANK DESCRIPTION' <br /> TANK ID# TANK MANUFACTURER <br /> COMPARTMENTALIZED TANK ❑ Yes No <br /> JaQ If"Yes",complete one page for each compartment. <br /> DATE INSTALLEDJ(Y[EA_R/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> v 2000 <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 /> (If marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED - "Ili3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑1e. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page) CAS#(trom Hazardous Materials Inventory page) <br /> Used oro <br /> 0 95, UNKNOWN <br /> tlL TANK CONSTRUCTION <br /> TYPE OF TANK 1, 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 <br /> 1199. 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 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 ❑ 5. GLASS LINING ❑95. UNKNOWN433 <br /> ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING 6. UNLINED ❑99. 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 ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2, SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLEDTYPE(Forkxal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT <br /> ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 10 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> .,., 11F.TANK LEAK flETEGTION <br /> IF SINGLE WALL TANK(Check all 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) ❑ 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 <br /> ❑89. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />