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tl <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS I <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 j <br /> (NHo pages per tang) ! <br /> Page _ of _ <br /> CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> TYPE OF ACTION ❑I.Nc^.Y SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 7, PERMANENTLY CLOSED ON SITE , <br /> (Check One Item only) <br /> ❑3.RENEWAL PERMIT (Spiny reason•forI-use Doty) (Srocdj change•forlocal use only) ❑ 6. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA•Oang Business As) <br /> FACILITY 10 a <br /> LOCATIONWITHIN SITE(ogcnao` 431 <br /> fid\ 1 C <br /> 1.TANK DESCRIPTION <br /> TANK M NUFACTURER COMPARTMENTALIZED T ❑ Yes % No <br /> TANK ID a ��� � it*Yee,complet;Iet e one page for each com r•rent. <br /> i` <br /> - J 4 4 TANK CAPC/A/C/1TY' IN GALLONS NUMBER OF COMPARTMENTS I - <br /> DATE INSTALLED(YEARMO) <br /> t0 - ( S �1ere, I . <br /> AOOITIONAL DESCRIPTION(Forlocal use oNy) �J <br /> tt.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE ❑ 5. JET FUEL <br /> c c a REGULAR UNLEADED ❑ 2. LEADED <br /> t-."Aled, <br /> M070R VEHICL-FU-L ❑ B. AVIATION FUEL complete Potr9%eun Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL <br /> ❑ 2. NON•FUEL PETROLEUM ❑te. MIDGRAOE UNLEADED <br /> ❑ 4 GASOHOL ❑99. OTHER <br /> CAS a(hnm Hazardous Materials Inventory page) <br /> ❑ 3. CHEMICAL PROCUCT COMMON NAME(from Nazaldaus Mat"als fnvonlory page) <br /> ❑ 4. HAZARDOUS WASTE(Incfud8s <br /> Used Oe) <br /> UNKNOWN III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL [33. SINGLE WALL WTH ❑ S. SINGLE'WALL WITH INTERNAL BLADDER SYSTcN. <br /> EXTERIOR MEMBRANE LINER ❑95. LINKNO'.A'N <br /> (Check one item only) DOUBLE WALL ❑ 4. SINGLE WALL IN A VAULT I-S ❑99. OTHER <br /> ❑95. UNKNOY:-4 <br /> TANK MATERIAL•prvary tank ❑ 1_ BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CLAD W1FIS=RGLASS C39. FRP COMPATIBLE W11C0%METHANOL C1 99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL•secondary tank ❑ i. BARE STEEL C]99. OOTHER❑ 3 FIBERGLASS I PLASTIC ❑ 6 FRP COMPATIBLE W1100%MET ❑9i M <br /> THER <br /> ❑ 4 STEEL CLAD YIIFIBERGLASS ❑ 9_ FRP NON•CORROOISLE JACKET <br /> (Check one item only) [:1 2. STAINLESS STEEL REINFORCED PLASTIC(FRP) <br /> ❑10 COATED STEEL <br /> ❑ 5 CONCRETE OATEINSTALLEO <br /> TANK INTERIOR LINING ❑ 3. EPDXY LINING ❑ 5 GLASS LINING C]SS. UNKNOW?7433 <br /> ❑ 1. RUBBER LINED ❑ 6. UNLINED ❑99. OTHER �-- <br /> OR COATING ❑ 4 PHENOLIC LINING (Forlacal use enFj) <br /> ❑ 2.ALKYD LINIt7G DATE INSTALLED <br /> (Check one dem onb) 474 <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 95. UNKNOWN _ <br /> PROTECTION IF APPLICABLE PROTECTION ❑99. OTHER (For local <br /> ❑ 4. IMPRESSED CURRENT <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE <br /> SPILL AND OVERFILL <br /> • YEAR INSTALLED TYPE(Forlocal use dnty) OVERFILL PROTECTION EQUIPMENT: R INSTALLED <br /> YEA <br /> ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> (Check as that apply) ❑ 1 SPILL CONTAINMENT <br /> �n ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> . DROP TUBE i <br /> ❑ 3. STRIKER PLATE . <br /> IV.TANK LEAK DETECTION <br /> • IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check 0110 item dnAp: <br /> IF SINGLE WALL TANK Check an Mat ap 1: ❑ $. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) Z. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE 20NE <br /> ❑ 3. CONTINUOUS ATG <br /> ❑ 7. GROUNDWATER ❑ 3. btANVALMON17pRING <br /> ❑ 4. STATISTICAL Ih'lENfTORY RECONCILIATION(SIR) <br /> ❑ 6. TANKTESTING <br /> BIENNIAL TANX TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN <br /> PLACE <br /> FILLED WITH INERT MATERIAL? <br /> ESTIMATED DATE LAST USED(YRIMOIOAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING <br /> gallons ❑Yes ❑No <br /> Formerly SWRCB For' <br />