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UNIFIED PROGRAM CONSOLIDATED FORM Z <br /> jp\?E�rTANKS <br /> UNDERGROUND STORAGE TANKS _TANK PAGE I (two pages per lank) <br /> Page_of <br /> TEMPORARY SITE <br /> TYPE OF ACTION ❑ 1NEW SITE PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANGE OF INFORMATION O 6 PERMANENTLY CLOSEDRED ON SITE <br /> (Check me item Only) 439 <br /> ❑ 3 RENEWAL PERMIT (Spcnfyreas0n-fw:Malm,rmI1) (Specifyreamn-fort oalme.dy) ❑ 8 TANK REMOVED I <br /> BUSMESSNAME(sa .FACu.ITYNAME or DBA-Doing Bwiness K) 3 <br /> FACILITY ID: va'xa a <br /> 431 <br /> LOCATION WIT IN SITE(Opborm0 0. y J D Y 4 S 3 7 <br /> 3 0 <br /> I.TANK DESCRIPTION.(A scaled plot plan with the location of the U 433 ST system including buildCQ pARTMENTALIZED TANKepa Yes local <br /> No agency.) 4N <br /> TANK IDR { 4n TANK MANUFACTURER <br /> O J H-yr ,mmplele o-page for each cmmmrmenrb <br /> 6S <br /> J435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4n <br /> D TE INSTALLED(YEAR/MO) <br /> 00 102-o0-ow I 00 433 <br /> DITI NAL DESCRIPTION(Fmlmalmeorly) <br /> II.TANK CONTENTS <br /> a4o <br /> TANK USE 439 PETROLEUMTYPE <br /> RI I. MOTOR VEHICLE FUEL ❑I.. REGULAR UNLEADED 02. LEADED 05. JET FUEL <br /> (ifmacked canplem Perm I..type) 4Q Ib. PREMIUM UNLEADED ❑3...DIESEL '0 6. AVIATION FUEL <br /> 02. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER M2 <br /> ❑3. CHEMICAL PRODVCT COMMON NAME (fmm xanNom Materials m.enmry pe¢e) <br /> 401 CASK Ifi.m HauNom Materiab lnvmbry pogo) <br /> [014. H WASTE <br /> (Include Ua4 Oil) <br /> ❑95.UNKNOWN <br /> TIL TANK CONSTRUCTION <br /> • HS <br /> TYPE OF TANK 1. SKGLE WALL 3. SINGLE WALL WITN S. SINGLE WALL WITH INTERNAL BLADDERS YSTEM <br /> EXTERIOR MEMBRANE LINER ❑95.UNKNOWN <br /> (Checkene item mly) <br /> �2. DOUBLE WALL ❑d.SIGNLE WALL N VAULT ❑99. OTHER <br /> TANK MATERIAL-primary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5.CONCRETE <br /> 95. UNKNOWN 441 <br /> (Check o-imm Orly) 112. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑& FRP COMPTIBLE W/100%METHANOL ❑99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-aec.ndary mnk 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE <br /> 95. UNKNOWN u5 <br /> (Cheok.nc imm Orly) ❑4.[12. STAINLESS STEEL STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL C399.OTHER <br /> REINFORCED PLASTIC(FRP) [I 10.COATEDSTEEL <br /> ❑5.CONCRETE <br /> TANK INTERIOR LINING LRUBBER LINED 3.EPDXY LINING S.GLASS LINING 95.INKNOWN <br /> 446 DATE INSTALLED 411 <br /> OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (For I-J use wo <br /> (amkoneitcmanly) 44g DATEINSTALLED 419 <br /> OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN <br /> PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER - <br /> (Fm Imd use Ody) <br /> (C3tmk one i.m ly) ❑2 SACRIFICIAL ANODEan <br /> SPILL AND OVERFILLYEARYEAR INSTALLED 450 TYPE(lenl uu only) <br /> ec451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Chkall NY <br /> aaVIY) I SPILL CONTAINMENT �^*0 2•O J 10 1 ALARM ❑3 FILL TUBE SHUT OFF VALVE <br /> [�2 DROP TUBE N 00 3 . O V p Y 2 BALL FLOAT ❑4 EXEMPT <br /> ®3 STRIKER PLATE J 0 ss <br /> 1V.TANKLEAK EC'TI )N(Adescriptianofinemonitonngpm¢nms lbeaubminedtonrelmalag yJ <br /> 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4$0 <br /> IF SINGLE WALL TANK(ebmkan mm apply) (cheek.-mem.dy) <br /> ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) [II VISUAL(SINGLE WALL <br /> M VAULT ONLY) <br /> b VADOSE ZONE MONITORING <br /> CONTINUOUS INTERSTITIAL MONITORG <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑7 GROUNDWATER ❑3 MANUAL MONITORING <br /> ❑J CONTINUOUS ATG <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION [I STANK TESTING <br /> (SIR) BIENNIAL TANKTESTING 0 9 OTHER <br /> IV.7ANK CLOSURE INTORMATION J PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF Sl1BSTANCE REMAKING 656 TANK FILLED W ITH INERT MATERIAL? <br /> an <br /> gallons ❑Yes ❑ No <br /> UPCF(12/99 revised) 10 Formerly SWRCB Form B <br />