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UNIFIED PROGRAM CONSOLIDATED FORM TANKS .UNDERGROUND STORAGE TANKS -TANK PAGE 1 Papa - of TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION ❑ & TEMPORARY SITE CLOSURE rAoa one dem mw ❑ 7. PERMANENTLY CLOSED ON SITE ❑ 3. RENEWAL (Specify mason - for/oca! use only) (Specify change - for kacad use oNy/ ❑ 8. TANK REMOVED 430 BUS11,41f,% NAME (Sarna as FACILITY NAME or DBA - DMV Busttess As) 3 1 FACILITY IDS i LOCATION WITHIN SITE (OpOW" - 431 1. TANK DESCRIPTION ANK _IDN 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑ No 11 'Yes'. complete one pagd fa each compartment 434 DATE INSTALLED (y ) 435 TANK ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 43 ADDITIONAL DESCRIPTION (For local use ONO 438 11. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ryc1�� MOTOR VEHICLE FUEL ❑ Ia. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (;marled. w HO0018 Petroleum Type) ❑ 1b. PREMIUM UNLEADED DIESEL ❑ 6. AVIATION FUEL ❑ 2. NOWFUEL PETROLEUM ❑ tc. MIDGRADE UNLEADED 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous MaseaYs Inventory page) 441 CAS X (born Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used OP) ❑ 95. UNKNOWN Ill. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check ane tem only) DOUBLE WALL EXTERIOR MEMBRANE LINER ❑ WALL IN A VAULT ❑ 95. UNKNOWN - 4. SINGLE ❑ 99. OTHER TANK MATERIAL -Primary tank 'Ql SME STEEL [33. FIBERGLASS/PLASTIC 95. UNKNOWN ❑ 5. CONCRETE 1:195.44 4 (Check one sera onry) L; 2. STAINLESS STEEL ❑ 4. STEEL CLAD ❑ 8. FRP COMPATIBLE W/100% METHANOL ❑ 99. OTHER W/FIBERGLASS REINFORCED PLASTIC FRP TANK MATERIAL - secondary tank ❑ 1 BARE STEEL t510$. FIBERGLASS / PLASTIC ❑ 8. FRP COMPATIBLE W/100% METHANOL ❑ 95. UNKNOWN 445 (Check one mm only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORROOIBLE JACKET ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 6. UNLINED ❑ 99. OTHER Check am tem only)For focal use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC UNKNOWN 446 DATE INSTALLED 448 PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 99. OTHER (Check are temwNy) ❑ 2. SACRIFICIAL ANODE (For local use onty) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (For local use orgy) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check all mat OA*) rZ 1. SPILL CONTAINMENT _2. ❑ 1. ALARM FILL TUBE SHUT OFF VALVE DROP TUBE ❑ 2. BALL FLOAT a. EXEMPT :r !°!� 3. STRIKER PLAOC N. TANK LEAK DETECTION IF SINGLE WALL TANK (Check an that apWY): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): 454 ❑ 1. VIS: AL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TA`.K GAUGING (MTG) ❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING (ATG) ❑ 6. VADOSE ZCtiE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTfNUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION (SIR) + ❑ S. TANK TESTING BIENN'Ai TANK TESTING [199. OTHER V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED LATE LAST USED (YRfMOIDAY) 455 ESTIMATED QUANTITv CF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (3;'991 Formerly SWRCB Form 8