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v UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per k) Page _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE 'L (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE I �fa �C 3.RENEWAL PERMIT (Specify mason-for local use only) (Specify change-forlocal use only) ❑ 8.TANK REMOVED 430 •�I1�0 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDK rG w- t 5 &5 9 lilQ LOCATION WITHIN SITE(Optionag 431 I.TANK DESCRIPTION7Z 11 O S TANK to k TANK MANUFACTURER COMPARTMENTALIZED TANK /I��Yes ❑ No If'Yes'.complete one pagdror aarh compartment. DATE INSTALLED(YEARIMO) - TANK CAPACITY IN GA ONS NUMBER OF COMPARTMENTS L9 ADDITIONAL DESCRIPTION(Forlocal use only) IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE �1. MOTOR VEHICLE FUEL -1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL '(Il marked,complete Petroleum Type) 91b. PREMIUM UNLEADED '3. DIESEL ❑ 8. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME( CAS If(from Hazardous Materials Inventory page) hem Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 1 17195 UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH - ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) fR2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN (Check one item only) I2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL oi. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED - ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2.ALKYD LINING ❑ 4. PHENOLIC LINING ❑ S. UNLINED ❑99. OTHER For local use only) (Check one item only) �3�,,,� OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC F!'-". UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (Forlocal use only) (Check one item only) ❑ 2. SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) R 1. SPILL CONTAINMENT 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE K2. DROP TUBE 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE FV 'TAN)41EM'DETEC7)ION"> . IF SINGLE WALL TANK Check all that apply), IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 01. VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE 2. CONTINUOUS INTERSTITIAL MONITORING 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING -04. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING 099. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B