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NIFIED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (two pages per tank) <br /> Page _ of _ <br /> TYPE OF ACTION IV1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE <br /> (Cheek one item only) <br /> 11❑3.RENEWAL PERMIT 7. PERMANENTLY CLOSED ON SITE <br /> (Specify mason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 vl <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID k 1 <br /> LOCATION WITHIN SITE(Ophone4 431 <br /> I.TANK DESCRIPTION <br /> TANK ID# TANK MANUFACTURER ❑ No <br /> COMPARTMENTALIZED TANK Yes <br /> If"Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS <br /> 5'. <br /> �vv <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> W1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (If marked,complete Petroleum Type) ®'1b. PREMIUM.UNLEADED 133. DIESEL ❑ 8.AVIATION FUEL <br /> 112. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(nom Hazardous Materials Inventory page) CAS It(from Hazardous Materials Inventory page) <br /> UseO;Q <br /> UNKNOWN <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK ❑aa i, SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one item only) ar�� 2. DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank 01. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item onty) ❑ 2. STAINLESS STEEL 104. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondarytank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/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) ❑10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2.ALKYD LINING 114. PHENOLIC LINING D6. UNLINED 1199. OTHER <br /> (Check one item only) (For local use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (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 tee( <br /> - I '�`•' ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVECL <br /> ❑ 2. DROP TUBE "? O �-� ❑ 2. BALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <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) ❑ 8. VADOSE ZONE ® 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ 8. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENTCLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? <br /> gallons <br /> ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />