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NI UFIED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT CHANGE OF INFOR/A! TION) / ❑ 8. TEMPORARY SITE CLOSURE (Check one item only) �, Jr' 11 /� f{ ,I/�&,. ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Spocity reason-for local use oMy) (Specify change r Ixalus oYnly) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID 0 1 S LOCATION WITHIN SITE(Opti nal) 431 I.TANK DESCRIPTION TANK 10 a TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes No If'Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS Q') j ADDITIONAL DE RIPTION(For local use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) It 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT CAS a(from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN j2L4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL A4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LININGDATE INSTALLED OR COATING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6 UNLINED ❑99. OTHER (For local use on ) (Check one item only) DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER (For local 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) 1. SPILL CONTAINMENT ❑ 1. ALARM IM3. FILL TUBE SHUT OFF VALVE Jam".2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT 3. STRIKER PLATE IV.TANK LEAK DETECTION IF SINGLE WALL TANK Check all that• IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item onl ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSE ZONE . CONTINUOUS INTERSTITIAL MONITORING ' ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ S. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B