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UNIFIED PROGRAM CONSOLIDATE0 FORM TANKS UNDERGROUND STORAGE TANK -TANK PAGE 1 (twopeges per tank) P gc of TYPE OF ACTION ❑1 NEW SITE PERMIT 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) [37 PERMANENTLY CLOSED ON SITE [33 RENEWAL PERMIT (Specify much-fm local use only) (specify human-for Intel meonly) ❑ 8 TANK REMOVED 430 1 BUSINESS NAME(samu eFACILITY NAME or DBA—Oo' gBusineu As) 3 FACILITY ID: R Tr 1 � LO ATION WITHIN SITE(optional) all 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# 433 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 ('7ar1'7 )P'Yei"complett one page for each comparment. DATE INSTALLED(YEAR/MO) 435TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADDITIONAL DESCRIPTION(Fm mleame only) (r57Uf 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 400 Al. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (Ifmmkcdemnplem Petroleum Type) ❑Ib. PREMIUM UNLEADED 143. DIESEL ❑ AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑ 9.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hvardou Materials Inventory,page) 441 CAS#(from Hazardous Materials Inventory page) 443 ❑4. HAZARDOUS WASTE (Inclodes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL3. SINGLE WALL WITH 5.'SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkone item only) EXTERIOR MEMBRANE LINER ❑95UNKNOWN �b. DOUBLE WALL [14. SIGNLE W ALL IN VAULT 0991 I OTHER TANK MATERIAL—primarywek Lj I. BARE STEEL 3, FIBERGLASS/PLASTIC Ll 5.I CONCRETE U 95. UNKNOWN 444 (Checkone item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. ('RPCOMPTIBLEW/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL—secondary lank 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC U 51 CONCRETE 95. UNKNOWN 445 (Checkone item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS 1381 FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑S. CONCRETE TANK INTERIRD 114c 0 1.RUBBER LINED 3.EPDXY LINBJG 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING 6 UNLINED ❑99 OTHER (For local use only) (Check one item only) 448 DATE INSTALLED 449 OTHER CORROSION ❑1 MANUFACTURED CATHODIC FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Fm laal use only) (Check ane item only) [32 SACRIFICIAL ANODE 451 OVERFIE PROTECTIONE UIPMENTMEAR INSTALLED ( 453 SPILL AND OVERFILL YEAR INSTALLED 19450 TYPE(local use only Q 9D (ChcckalUhmapply) IQ I SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE 0 T IV.TANK LEAKDETECTION(A description ofthe mentioning progro shell be submitted to the local agency.) IF SINGLE WALL TANK(neck all mat apply) 453 IF DOUBLE WA LL TANK OR TA NK WITH BLADDER 454 (Check ane item only) ❑I 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 ❑STANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTI MATED DATE LAST USED(YR/MO/DAY) 055 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B