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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) P ge of TYPE OF ACTION ❑I NEW SITE PERMIT t 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) -- ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-fm howl use only) (Specify reason-ter local a only) ❑ 8 TANK REMOVED 430 h BUSINESS NAME(s.me as FACILITY NAME or DBA-Doing FACILITY ID:ausinws As) 3 rah v��o�� 431 LOCATION WITHIN SITE(opao�u9 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes M No 434 M1i If-Yes",complete one page for each comp atment. DATE INSTALLED(YEAR/MO) d35 TANK CAPACITY IN GALLONS 435 NUMBER OF COMPARTMENTS 437 1 ZLI Qt �l ADDITIONAL DESCRIPTION(For local one only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 940 I. MOTOR VEHICLE FUEL ❑I.. REGULAR UNLEADED ❑2. LEADED ❑ JET FUEL (If marked complete Petroleum Type) ❑Ib. PREMIUM UNLEADED (0(3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL 1319 9.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME Timor Hazardous Materials Inventory page) 441 CAS#(fmmxazerdooa Mamrialsh ostorypage) 062 [14. HAZARDOUS WASTE (Relation Used Oil) ❑95.UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL U 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE,WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL- tank 1. BARESTEEL 3. FIBERGLASS/PLASTIC zz 5. CONCRETE 95. UNKNOWN 444 p m ry (Ceeckone i.em only) [12. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRPCOMPTIBLEW/100y METHANOL 099.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-scmndary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5: CONCRETE 95. UNKNOWN 445 (Chock one item only) [12. STAINLESS STEEL 4. STEEL CLAD W/FBERGLASS ❑8.. FRP COMPTBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10,COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING M 1.RUBBER LINED 11 3.EPDXY LINING ,,s�, 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING p{ll6 UNLINED ❑99 OTHER (Check enc item only) l" (For lam use onlD 448 DATE INSTALLED 449 OTHER CORROSION ❑1 MANUFACTURED CATHODIC )d3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IFAPPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Far local vu only) (Check one item only) ❑2 SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 1 p450 TYPE(local on only) 451 OVERFU.L PROTECTION EQUIPMEN PYEAR INSTALLED k0kg0 452 (Checkmllhatapply) 0(I SPILL CONTAINMENT 0 ALARM ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT�fdl ��❑4 EXEMPT ❑3 STRIKER PLATE '"""z"- �od IV.TANK LEAK DETECTION(A descfipiian ofine mommrins peosram ae.n he wbmeted to tee I..l agca.y.) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 IF SINGLE WALL TANK(Check all that apply) (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I 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 ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons []Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B