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0 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (Iwo pages er tank) Page of TYPE OF ACTION ❑INEW SITE PERMIT I AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ry (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reamn-far local uuonly) (Specify reason-for local one only) ❑ 8 TANKREMOVED 430 USINE S NAME(Satacu FACILIWN Eor DB s amcss As) FACILITY ID: 1 1 �� 1�WE t LOCA ION WITHIN SITE(optfra0 431 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 No 434 I0 6 If'Tes-,completeone page far each cmnpenmevt. DATE INSTALLED(YEARIMO) 435 TANK CAPACITY IN GALLONS 436 1 NUMBER OF COMPARTMENTS 437 U 01 5 ADDITIONAL DESCRIPTION(For local aw only) 438 II.TANK CONTENTS .ap(t TANK USE 439 PETROLEUM TYPE 440 to I. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED ❑ . JET FUEL (if marked complete Peaalewo Type) 016. PREMIUM UNLEADED ❑3. DIESEL .�❑pks . AVIATION FUEL 7 02. NON-FUEL PETROLEUM ❑le. MIDGRADE UNLEADED 04. GASOHOL 9.OTHER- (j` ❑3. CHEMICAL PRODUCT COMMON NAME them Hwancen,Moderate InveneoU page) 461 I CAS#(from HewWwe Materials Inventorypage) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK El 1. SINGLE WALL 3. SINGLE WALL WITH Li 5. INGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) tta5 EXTERIOR MEMBRANE LINER ❑95. UNKNOWN W 2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary tank Lj 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 444 m (Check one iteonly) [32. STAINLESS STEEL 4. STEEL CLAD W/RBERGLASS E]8. FRP COMPTIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-swarth"ank Lj 1. BARE STEEL 3. FIBERGLASS/PLASTIC S. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) 1-110,COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING95.UNKNOWN 446 DATE INSTALLED 447 OR COATING [32 ALKYD LINING [34 PHENOLIC LINING p 6 UNLINED ❑99 OTHER (Check one item only) For I«d uuonly) 448 DATEINSTALLED 449 OTHER CORROSION ❑1 MANUFACTURED CATHODIC A3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT i ❑99 OTHER (Dwkone itonowly) [12 SACRIFICIAL ANODE trorlocil uao only) 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 11gO 452 SPILL AND OVERFILL YEAR INSTALLED I I90 (Ch«kallthatnpply) QMI SPILL CONTAINMENT ❑1 ALARM ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE IV.TANK LEAK DETECTION(A denwiption oRhe monitoring program ahail be submitted to the local age«y.) IF SINGLE WALL TANK(Ch«kau that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 450 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) Xr2 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 0 9 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED 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