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UNIFIED PROGRAM CONSOLIDATED FORM 1 X SKS <br /> RGROUND STORAGE TANKS-TANK E I g� L I- <br /> UNDE (two pages per tank) <br /> Page-of <br /> -�. [3 7 PERMANENTLY CLOSED ON SITE 430 <br /> TYPE OF ACTION ❑INEW SITE PERMIT ❑ <br /> 4 AMENDEDPERMIT 611 5 CHANGE OF INFORMATION (36 TEMPORARY SITE CLOSURE <br /> (Check one inm only) STANK REMOVED <br /> ❑ 3 RENEWAL PERMIT (SPcdfyma...far leeal ass on <br /> (Specify mown f la lun oNy) ❑ <br /> FACILITY ID: yer <br /> J aD 1 <br /> BUSINESS NAME(Samess FACLLD'YNM'IE or DBA-Doingg1l" ess N) 431 <br /> (ON I G N M oc �"f�v D✓ jvu G cl S 37>t <br /> LOCATION WITHIN SITE(opaamp O <br /> me <br /> 4v COMPARTMENTALIZED TANK N Yes ❑ No <br /> I.TANK DESCRIPTION.(A scaled plot plan with the location of the UST system including build-mgs and landmarks shall be s mined to the Iota agency. <br /> 43z TANK MANUFACTURFR If"Yn,opI one page for each eampon-1 <br /> TANK ID# 11sn <br /> 505 TANK CAPACITY M GALLONS 436TJUMBER OF COMPARTMENTS <br /> DATE INSTALLED(YEAR/MO) IS <br /> 1D 004 • <br /> ADDITIONAL DESCRIPTION(For"meanly) <br /> II.TANK CONTENTS 44a <br /> TANK USE 439 PETROLEUMTYPE <br /> 5. JET FUEL <br /> 1 1.MOTOR VEHICLE FUEL ❑In. REGULAR UNLEADED 3.DIE2. SEL '[16. AVIATION FUEL <br /> (Irmer4edoneplen Pewlevm Type) ❑ Ib. PREMIUM UNLEADED 4. GASOHOL ❑99.OTHER H2 <br /> a2.NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED a4I CAS#(amm slavrdam Manrialalmmnry page) <br /> ❑J CHEMICAL PRODUCT COMMON NAME (fin.K-Manria4lnvennry page) <br /> 0 4. HAZARDOUS WASTE <br /> (Inclwka Used Oil) <br /> 095.UNKNOWN llI.TANK CONSTRUCTION au <br /> LBLADDERSYSTEM <br /> TYPEOFTANK I. SINGLE WALL GLE <br /> 3. SINWALL WITH S. SINGLE WALL WITH INTEANA <br /> EGLE RMEMBRANE LINER 095.UNKNOWN <br /> (Checkoneii only) NLE WALLIN VAULT 099. OTHER <br /> 2. DOUBLE WALL ❑4.SIG95. UNKNOWN 4K <br /> TANK MATEIll AL-prin'arY wJe 1. BARE STAINLEEEL SS <br /> 3. FIBERGLASS/PLASTIC 5.CONCRETE <br /> (anekoneinm only) ❑2. STAINLESS STEEL <br /> 4. STEEL CLAD W/FIBERGLASS ❑S. ERP COMPTIBLE Wy100°h METHANOL [199-OTHER <br /> REINFORCEDPLASTIC(FRP) 95. UNKNOWN GS <br /> TANKMATERIAL-seeoaduymnk STAINLESS 1. SS <br /> EEL 1119, 3:FIBERGLASS/PLASTIC 5. CONCRETE <br /> ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS e. FRP COMPTIBLE W/100%METHANOL 099.OTHER <br /> (Check one III only) REINFORCED PLASTIC(FRP) ❑10.COATED STEEL <br /> ❑S.CONCRETE 446 DATEINSTALLED 447 <br /> I.RUBBER LINED 3.EPDXY LINING <br /> S.GLASS LINING 95.UNKNOWN <br /> TANK INTERIOR LINING 99 OTHER (porlawl use only) <br /> ORCOATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6lJNLINED ❑ DATE INSTALLED 449 <br /> (CheekoneinmoNy) 95 UNKNOWN <br /> OTHER CORROSION ❑I MANUFACTURED CATHODIC ION Q C�NPRESSfiDS CREINFM CED PLASTIC []99 OTHER (Fa localNoe oNY) <br /> PROTECTION IF APPLICABLE 2 SACRIFICIAL ANODE PROTECT 45z <br /> (Cheek one inmoaly) 45o TYPE lkvl me onlY> 451 OVERFILL.RO I ECIION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL YEAR INSTALLED q <br /> O t � 1 ALARM n�kJOoS., >❑3 FILL TUBE SHUT OFF VALVE <br /> (@wk ellanrepply) qILII SPILL CONTAINMENT O `70 ,2 ALL FLOAT�k G>7-VI4 EXEMPT <br /> 1p 2DROP TUBE A003 , Oo <br /> 3 STRIKER PLATE S O D -11 <br /> O' <br /> IV.TANK LEAK DETECTION(Adesebpa4^arae monnodng prognn awi x aakminN n un local agmavJ 4w <br /> 453 IF DOUBLE W ALL TANK OR TANK WITH BLADDER <br /> IF SINGLE W ALL TANK(Cheek NI app apply) (Cheek aee in n aNy) <br /> ❑IYISUAL(EXPOSED PORTION ONLY) CO35 MANUAL TANK GAUGING(MTG) 131 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 06VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑2 AUTOMATIC TANK GAUGR40(ATG) ❑7 GROIN 3 MANUAL MONITORING <br /> ❑3 CONTINUOUS ATG <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑g TANK TESTING <br /> (SIR) BIENNIAL TANKTESTING <br /> ❑99 OTHER <br /> IV.TANK CLOSURE INFOILNATION/PERMANENT CLOSURE IN PLACE 457 <br /> 4� TANK FILLED WRHINER7 MATE0.IAL7 <br /> 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING ❑Y,e% No <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) gallons <br /> 10 Formerly SWRCB Form B <br /> UPCF(12/99 revised) <br />