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1 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pages per tank) Page _ of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ S. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one item only) ❑ 7. PERMANENTLY CLOSED ON SIT -� ❑3.RENEWAL PERMIT (Specify reason-for local use only) (Specify change-for local use only) ❑ 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# LOCATIO WITHIN SITE(Optional) �� 431 1.TANK DESCRIPTION TANK ID# K MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes ❑ No - .--� If'Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS urns'..- / ADDITIONAL DESCRIPTION(Forlocal use only) 11.TANK CONTENTS TANK USE 432 PETROLEUM TYPE MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED . LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c MIDGRADE UNLEADED ❑ 4. GASOHOL [199, OTHER ❑ 3. CHEMICAL PRODUCT CAS# from Hazardous Materials Inventory page) COMMON NAME(from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE(Includes Used Oil) 95, UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) ❑ 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER TANK MATERIAL-primary tank 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195, 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 tank1 BARE STEEL 113. 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) ❑10 COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING 1195. UNKNOWN433 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING . UNLINED ❑99. OTHER (Check one item only) (For local use only) OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC 5. UNKNOWN 434 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. 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))�'y11. ❑ 1 SPILL CONTAINMENT ❑ 1.ALARM ❑ 3. FILL TUBE SHUT OFF VALVE N " ❑ 2. DROP TUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT N� ❑ 3. STRIKER PLATE IV.TANK LEAK DETECTION IF SINGLE WALL TANK Check all that apply): 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 ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)♦ ❑ 8. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? jq gallons ❑Yes o CUPAFORM(4/99) r-ow -/ • Formerly SWRCB Form B