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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT S. CHANGt4F i ORMA ON) <br /> ❑ S. TEMPORARY SITE CLOSURE } \� <br /> (Check one item only) ❑ 7. PERMANENTLY CLOSED ON E <br /> ❑3.RENEWAL PERMIT change-for local use only) ❑ 8. TANK REMOVED 430 <br /> (Spaclly reason-for local use only) (Specify ng <br /> 1 <br /> r <br /> USINES AME(Same as FACIUTYNAME or OBA-Doing Business As) ACILITYID UOCATION WITHIN SITE(Optionag 431 <br /> 1.TANK DESCRIPTION <br /> M <br /> TANK IDV 4./ TANK ANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ Na <br /> 6 � � 11*yes*,complete one page for each compartment. <br /> NUMBER OF COMPARTMENTS <br /> -ATE INSTALLED CfEAR/MO) <br /> TANK CAPACITY IN GALLONS <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> it.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> ❑ 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED <br /> (It marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM [34. GASOHOL ❑99. OTHER <br /> ❑tc. MIDGRADE UNLEADED <br /> ❑ 3. CHEMICAL PRODUCTCAS S(from Hazardous Materials Inventory page) <br /> COMMON NAME(from Hazardous Materials Inventory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Used 0,0 <br /> C1 95 UtjKNQWN III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> (Chock one item oMy) ❑ 2. DOUBLE WAIL ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC C15 CONCRETE ❑95. UNKNOWN <br /> (Check one dam 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 I PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL C]95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4, STEEL CLAD W/FIBERGLASC1 9 FRP <br /> REINFORCED PLASTIC(FRSs [1 0 COATED STEELOODIBLE JACKET C399. OTHER <br /> ❑ 5. CONCRETE <br /> DATEINSTALLED <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNONrN4J3 <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED 99. OTHER (Forlocal use on ) <br /> (Check one item onl) DATE INSTALLED <br /> OTHER CORROSION ❑ t MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER <br /> ❑ 4. IMPRESSED CURRENT (For local use only) <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL ANO OVERFILL <br /> YEAR INSTALLE- TYPE(For local use Doty) OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED <br /> (Check all that apply) ❑ 1 SPILL CONTAINMENT ❑ 1.ALARM ❑ 3 FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROP TUBE ❑ 2. SALLFLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one iten1: <br /> IF SINGLE WALL TANK Check ell that a /:VISUAL(EXPOSED PORTION ONLY) 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VAOOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 6. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRAMO/OAY) <br /> 435 TANK FILLED WITH INERT MATERIAL? <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> gallons ❑Yes ❑No <br /> Formerly SWRCB Form B <br /> CUPAFORM(4/99) <br />