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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 6V (two pages per tank) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SITE ❑3.RENEWAL PERMIT (Specify reason-forlocal use only) (Specify change-forlocal use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) _ FACILITY ID# `" 1 LOCATION WITHIN SITE(Op#onao 431 r i `- I.TANK DESCRIPTION TANK ID# TANK MANUFACTUR R COMPARTMENTALIZED TANK ❑ Yes o 0-5 40 7 J4210 If'Yes',complete one page for each wm artment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS - s--:: l I Soo ADDITIONAL DESCRIPTION(For local use only) c IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE ❑ 1. MOTOR VEHICLE FUEL Ella. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICALPRODUCT ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME prom Hazardous Materials Inventory page) CAS#(from Hazardous Materials Inventory page) Used Oil) 95, UNKNOWN IU.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 1:195. UNKNOWN ❑ 4. 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 ❑4. 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 W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) 1110. 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 6. UNLINED ❑99.OTHER (Check one dem on ) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT 1199. OTHER (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all that apply) ❑ 1 SPILL CONTAINMENT C� 5(r 111. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE 112. DROP TUBE / G) ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE tV:^LANK LEAK DETECTION IF SINGLE WALL TANK Check all that a IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE . CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG - ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING BIENNIAL TANK TESTING 1199. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) - ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons - ❑Yes ❑No r CLIPAFORM(4/99) Formeily SWRCB Form B