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AdL, AM <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 TANKS <br /> (two pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION Or,NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Check one item only) <br /> ❑3.RENEWAL PERMIT ❑ 7. PERMANENTLY CLOSED ON SITE <br /> (Specify reason-for local use only) (Specify charge-for local use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# „ 1 <br /> ct��cz� N <br /> LOCATION WITHIN SITE(OplionaQ 431 <br /> TANK ID# TANK MANUFACTURER I.TANK DESCRIPTION <br /> COMPARTMENTALIZED TANK Yes ❑ No <br /> Q.*-� � If'Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACI IN GALLONS ✓ NUMBER OF COMPARTMENTS <br /> 15 <br /> ADDITIONAL DESCRIPTION(Forlocal use only) <br /> 11.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> W1. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ S. JET FUEL <br /> (If marked,complete Petroleum Type) 91b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 8. AVIATION FUEL <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 2. L PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 4. HAZARDOUS WASTE(includes COMMON NAME(Bom Hazardous Materials Inventory,page) CAS#(from Hazardous Matedals Inventorypage) <br /> Used Oil) A_ <br /> 11 1.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) rP 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT <br /> 1199. OTHER <br /> TANK MATERIAL-primary tank 01. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE <br /> ❑95. UNKNOWN <br /> (Check one item 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 ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL 04, STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) 1110, COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING <br /> OR COATING ❑ 1. RUBBER LINED 113. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> (Check one dem <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING 10 6. UNLINED ❑99. OTHER <br /> onl) <br /> OTHER CORROSION (For local use only) <br /> PROTECTION IF APPLICABLE ❑ 1. MANUFACT:ANODE <br /> THODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTIO ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIA <br /> (For local use only) <br /> SPILL AND OVERFILL - YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) 1 SPILL CONTAINMENT , <br /> 4 ©r"-^� ❑ 1 ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> 112. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> 1V. TANK LEAK DETECTION' <br /> IF SINGLE WALL TANK Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one item only): <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ® 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ E. TANK TESTING <br /> BIENNIAL TANK TESTING <br /> ❑89. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> 11 Yes ❑No <br /> :UPAFORM(4/99) Formerly SWRCB Form r- <br />