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UNIFIED PROGRAM CONSOLIDATED FORM r�' DS I7gO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 <br /> (faro Pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT Era AM NDEEl 5. CHANGE OF INFORMATION) ❑ 0. TEMPORARY SITE CLOSURE <br /> (Check one item only) .1 vv (tea ❑ ]. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT fSpxi/y reaaan-Forlxal use only) (Spxify cMlge-holowl use only) ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY IDN t <br /> El 0ra,cl Au-b 1 l3 oti <br /> LOCATION WITHIN SITE(Opti 431 <br /> 'b0�►O El 0 <br /> 1.TANK DESCRIPTION <br /> TANK 100 TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes @9- <br /> I ' p �• If'Yea',complete one page for seen mmpaament. <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY INNGGA1ILLONS NUMBER OF COMPARTMENTS <br /> 500 <br /> ADDITIONAL DESCRIPTION(Forlxal uss only) <br /> U.TANK CONTENTS <br /> TANK USE 412 PETROLEUM TYPE <br /> ❑ 1. MOTOR VEHICLE FUEL ❑1a. REGUTARUNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> (IfmaMeQ pompleM Petmlevm Type) ❑UP. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATION FUEL <br /> ❑ 2. NONFUELPETROLEUM ❑1c. MIOGRADEUNLEADED ❑ 4 GASOHOL ❑99. OTHER <br /> ❑ 3 HEMICAL PRODUCT <br /> AZAROOUS WASTE(hoph des COMMON NAME(hom H9Smob.S Matelots Ineaolorypag•) CAS N(fop Hazardous Materials Inv nforypage) <br /> Used Oip <br /> 95 UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK 1. SINGLE WALL ❑ 3. SINGLE WALL WTH ❑ 5. SINGLE WALL`MTH INTERNAL BLADDER SYSTEM <br /> (Check one item onry) ❑ 2 OOUBIEWALL EXTERIOR MEMBRANE LINER 095. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank 1. BARESTEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 0 9. UNKNOWN <br /> (Clrockmlai(emoory) ❑ 2, STAINLESS STEEL ❑4. STEEL CUD WIFISERGUSS ❑ 9. FRP COMPATIBLE WIT 00%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 0. FRP COMPATIBLE W1100%METHANOL ❑95. UNKNOWN <br /> (Chxkunakem onry) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CUD WARSERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET El 99. OTHER <br /> REINFORCED PLASTIC(FRP) 1110. COATED STEEL <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LINING ❑ 1 RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNONM433 DATE INSTALLED <br /> OR COATING <br /> ❑ Z. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ S. UNLINED ❑99. OTHER <br /> (Check onsite.onl J (FPrlxel use onl) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 113. FIBERGLASS REINFORCED RUSTIC ❑95. UNKNOWN 434 DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT 099. OTHER <br /> (Check am item oMy) ❑ 2. SACRIFICIAL ANODE (Forlxal use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlosaluse on OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED <br /> (Check all that apply) ❑ 1. SPILL CONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE <br /> ❑ 2. DROPTUBE ❑ 2. SALL FLOAT ❑ 4. EXEMPT <br /> ❑ 3. STRIKER PLATE <br /> -N:TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Check all that apply: I IF DOUBLE WALL TANK OR TANK WITH BUDDER Check one ifamo <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 8. VADOSEZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ ?. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ B. TANKTESTING <br /> BIENNIAL TANK TESTING 11 99, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PUCE <br /> ESTIMATED DATE LAST USED(YR)MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINI NG 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> QjfT j0 I <br /> R�IR1ol <br /> CUPAFORM(4/99) omerly SWRCB Form B <br />