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UNIFIED PROGRAM CONSOLIDATED FORM 7TANKSUNDERGROUND STORAGE TANKS -TANK PAGE 1 � // Paoe of /b TYPE OF ACTION L7 1 NEW SITE PERMIT C3 4. AMENDED PERMIT C:1 S. CHANGE OF INFORMATION) C3 TEMPORARY SITE CLOSURE (Cnxk on.dem only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT (Specify nuon-for local use orVy) (Specify charge-for local use only) ❑ 6. TANK REMOVED 430 -FF BUSINESS NAME(Sam.as FACILITY NAME or DBA-Do-ng Busv»ss As) FACILITY 10 a 11 L o� es CGILkLj S�,- ' �a3 abl�GS LOCATION WITHIN SITE(Opoon-0 431 �f /I _0 5-L/ K I.TAN DESCRIPTION TANK ID a ETANKCTURER COMPARTMENTALIZED TANK ❑ YIf'Y.i,com0l.n on.Page fa.aN comDanment DAT STALLED OI Y IN GALLONS Q' -F NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(For local We only) 11.TANK CONTENTS // TANK USE 432 PETROLEUM TYPE lam't MOTOR VEHICLE FUEL Cl la REGULAR UNLEADED ❑ 2�},FADED ❑ 5 JET FUEL pt marked.comp/eb Petmleum Type) C1 lb PREMIUM UNLEADED L1�1•"3/DIESEL ❑ 6 AVIATION FUEL ❑ 2 NON-FUEL PETROLEUM ❑1c. k410GRADE UNLEADED ❑ 4. GASOHOL ❑99 OTHER ❑ 3 CHEMICAL PRODUCT fY Pte) CAS a(fmm Hazamous M&401413 10~10'y page) COMMON NAME(hdm Hazardous Materials InMnro • Z ❑ 4 HAZARDOUS WASTE(Includes 0-,j - ,j y - 2 O; I D Y^ 1110d eco rV\ �}- O / r III.TANK CONSTRUCTION TYPE OF TANK ❑ 1 INGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5 SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Chock one dem only) 2. DOUBLE L EXTERIOR MEMBRANE LINER ❑95 UNKNOWN \/+ � OI�1 ❑ 4. SINGLE WAIL IN A VAULT ❑99 OTHER TANK MATERIAL-pnmary tank 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5 CONCRETE ❑95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 6 FRP COMPATIBLE W/100%METHANOL [:199. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑95. UNKNOWN (Check one Item only) ❑ 2. STAINLESS STEEL E�4 STEEL CLAD WIFIBERGLASS ❑ 9 FRP NON-CORROOIBLE JACKET ❑99. OTHER REINFORCED PLASTIC(FRP) ❑10 COATED STEEL ❑ 5. CONCRETE DATEINSTALLEO TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5 GLASS LINING ❑95. UNKNOWN433 OR COATING ❑ 2, AlKYO LINING ❑ 4 PHENOLIC LINING [11-rUNLINED ❑99 OTHER (For local use on 1 (Cnxk one demo I DATE INSTALLED OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 434 PROTECTION IF APPLICABLE PROTECTION r�-t� IMPR€SSEDC�1 RRrENT ❑99 OTHER (Fa mal use only) (Cnxk one dem onyl 912. SACRIFICIAL ANODE Uts YEAR INSTALLED TYPE/For loch u•only/ OVERFILL PROTECTION EQUIPMENT.YEAR INSTALLED SPILL AND OVERFILL n (Cnxk as that apply) 1. SPILL CONTAINMENT 1�. ALARM ❑ 3 FILL TUBE SHUT OFF VALVE CG-If.-If. DROP TUBE �� C�- LJ 2 BALL FLOAT 2i�aU ❑ 4 EXEMPT LY7. STRIKER PLATE 22 JO IV.TANK LEAK DETECTION IF DOUBLE WALL TANK OR TANK WITH BLADDER Check one Item IF SINGLE WALL TANK Check as that a ): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1�CONTISUA (SINGLE WALL IN VAULT MONITORING . ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE C3 3. MANUAL MONOUS INTERSTITIAL IAONITORING ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ ]. MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION(SIR)• ❑ 6. TANK TESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRiMWAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? gallons ❑Yes ❑No Forrnerty SWRCB Form B CUPAFORM(4199)