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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br />TANKS <br />Page _ Of _ <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT AMENDED PERMIT E35. CHANGE OF INFORMATION) ❑ B. TEMPORARY SITE CLOSURE <br />fumck am ire onw ❑ 7. PERMANENTLY CLOSED ON SITE <br />❑ & RENEWAL (3Xjj reason - for/ocW use only) (Specify change • for local use ❑ e. TANK REMOVED 430 <br />NAME (Same as FACILITY NAME or D Dosrg Business As) 3 <br />FACILITY ID S <br />`.i <br />W <br />m <br />f <br />:7m/tdt*__ <br />WITHIN SITE 11000n" 431 <br />1. TANK DESCRIPTION <br />TANK IDS 432 <br />TANK MANUFAC UR R 433 <br />COMPARTMENTALIZED TANK C3 yes ❑ No 434 <br />t <br />n . e <br />If 'Yes*. complete one page for each compwbmm. <br />O INSTALLED (Y ) 435 <br />TANK CAPACITY IN GALLONS 436 <br />NUMBER OF COMPARTMENTS 437 <br />1 ! <br />'z Ine-0 <br />AOCITioNAL DESCRIPTION (For local use only) 436 <br />N. TANK CONTENTS <br />TANK USE 439 <br />PETROLEUM TYPE 440 <br />1. MOTOR VEHICLE FUEL <br />'Type) <br />a. REGULAR UNLEADED ❑ 2. LEADED 13S. JET FUEL <br />• Petroleum <br />61-1PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br />❑ 2. Wn-FUEL PETROLEUM <br />❑ le- MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER <br />❑ 3. CHEMICAL PRODUCT <br />COMMON NAME (ft- Hazardous Matenats Mventory pager) 441 <br />CAS S Irrorre Hazardous Malsdals Mverrtory page) 442 <br />❑ 4. HAZARDOUS WASTE (incudes <br />Used OD <br />❑ 9s. UNKNOWN <br />IIL TANK CONSTRUCTION <br />TYPE OF TAW ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL NTH INTERNAL BLADDER SYSTEM 443 <br />EXTERIOR MEMBRANE LINER 139S. UNKNOWN <br />(Check one dem may) Cw.DOUBLE WALL <br />❑ 4. SINGLE WALL IN A VAULT <br />❑ 98. OTHER <br />TANK MATERIAL - pdmaty lank v1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE 139& UNKNOWN 444 <br />(Check one Mn ordy) ❑ 2. STAINLESS STEEL 0 4. STEEL LAD ❑ a. FRP COMPATIBLE W/100% METHANOL 1399. OTHER <br />WMB <br />REINFORCED PLASTIC FR <br />y� <br />TANK MATERIAL- sercondary tank C]1. BARE STEEL J' . FIBERGLASS I PLASTIC ❑ B. FRP COMPATIBLE W/100% METHANOL ❑ 95. UNKNOWN 445 <br />(Check one sem Doty► ❑ 2. STAINLESS STEEL 04. <br />P ❑ 9 FRP 14ON-CMRODIBLF JACKET ❑ 99. OTHER <br />REINFORCED LASTIC (FRP) <br />❑ 10. COATED STEEL <br />❑ 5. CONCRETE <br />TANK INTERIOR LINING ❑ 1, RUBBER LINED ❑ 3. EPDXY LINING ❑ & GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 <br />OR COATING <br />❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ :UNLINED ❑ 99. OTHER <br />/Deal use <br />Foronly) <br />one rtnn <br />OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 5. UNKNOWN 446 DATE INSTALLED 449 <br />PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 99. OTHER <br />(Check one item anIW ❑ 2. SACRIFICIAL ANODE (For/oea/ use only) <br />SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (For/ocal use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 <br />1 1. SPILL CONTAINMENT ❑ 1. ALARM 3. FILL TUBE SHUT OFF VALVE <br />Mat appy) 63 <br />(Check as <br />99 ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br />tt'11-2. DROPTUSE <br />3. STRIKER PLA49C - <br />s IV. TANK LEAK DETECTION <br />IF S6NGLE WALL TANK (Check ad that aoply): 453 <br />IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): 454 <br />❑ 1. visuAL (EXPOSED PORTION ONLY) ❑ 5. MANUAL TANi< GAUGING (MTG) <br />❑ 1. VISUAL (SINGLE WALL IN VAULT ONLY) <br />❑ 2. AUTOMATIC TANK GAUGING (ATG1 ❑ 6. VADOSE ZCNE <br />❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br />❑ 3. cc-;rNUOUS ATG ❑ 7. GROUNDWATER <br />❑ 3. MANUAL MONITORING <br />❑ 4. S7A'iSTSCAL INVENTORY RECONCILIATION (SIR) - ❑ S. TANK TESTNG <br />BIENNIAL TANK TESTING ❑ 99. OTHER <br />V. TANK CLOSURE INFORMATION ) PERMANENT CLOSURE IN PLACE <br />ESTIMATE,? CATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITr CF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br />gallons ❑ Yes ❑ No <br />UPCF ( %1S9) Formerly SWRCB Form B <br />