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U NIFIED PROGRAM C ONSOLIDATED F ORM DL <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 1 1� <br /> (M pa;69 pn,tank) <br /> Page _ or <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ a. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARYSITE CLOSURE <br /> (Chea one item erYY) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ].RENEWAL PERMIT (SPecily-an.lorbcal uae aaw (Specify Phanpe-brlecal vse aMy) ❑ B. TANK REMOVED A]D <br /> BUSINESS NAME <br /> Jof ifuTFACI�U�l vEL G� �Ib FACILTY IO F V <br /> R; oa�fj/ <br /> LOCATION VHITpWna7 D��S (h,l'at <br /> o fr <br /> I.TANK DESCRIPTION <br /> TANK IOY TANK MANUFACTURER COMPARTMENTAL ZED TANK �Y s ❑ No <br /> / '�) aT/�/ If• fs'. omplale and <br /> pa9efw eaN�mpaRTen1 <br /> DATEINSTALLED(YEARMO) J\ TANKCAPACIWiN GGALLLOCNS w /"fA L9 NUMBER OF COMPARTMENTS <br /> u�urr / 99 � /� coo 3 <br /> ADDITIONAL DESCRIPTION(FPrbcal use awry) (T � / e/ b� nl F 1 - r 1lba <br /> f !q (,11..TANK CONTENTS <br /> l'� <br /> TANK USE 432 7REIUR <br /> M TYPE <br /> .�.� 1eADED ❑ 2. LEADED Cl 5 JET FUEL <br /> IN 1 MOTOR VEHICLE FUEL ❑ 6. AVIATION FUEL <br /> (Ilmarke6,compre(e PefmNum Type) 0 16DED ❑ ]. DIESEL <br /> ❑ Z. NON-FUEL AOED ❑ e. GASOHOL ❑99. OTHER <br /> ❑ ]. CHEMICALPRODUCT COMMON NAME(nem Haaaidous MareLa9 lnwnf0q Pn0) CAS I(fmm Hazedfoom Marehals lnwnro Page) <br /> ❑ a. HAZARDOUS WASTE(IncluEea G��J'o /� A QO _6/_ <br /> UAZARD V V <br /> 111.TANK CONSTRUCTION <br /> TYPE OF TANK I. SINGLE WALL ❑ ]. SINGLEWALLWTH ❑ 5. SINGLE WALL WITH INTERNAL BUDDER SYSTEM <br /> � I EXTERIOR MEMBRANE LINER [395. UNKNOWN <br /> (Check om Ilam way) Ud-2. DOUBLE WALL 4, SINGLE WALL IN A VAULT <br /> ❑99. OTHER <br /> TANK MATERIAL phma,y tank ❑ ]. FIBERGLASS I PLASTIC ❑ 5. CONCRETE ❑9y UNKNOWN <br /> ❑ 1. RE STEEL <br /> (Clrcck one item awry) AINLESS STEEL sTEELCLADWIFIBERGIASS ❑ a FRP COMPATIBLE W'100%METHANOL <br /> [3 99. OTHER <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secwEary lank Cl 1 BARE STEEL ❑ ]. F ERGIIaSS I PLASTIC ❑ 6. FRP COMPATIBLE WIWO%METHANOL ❑95. UNKNOWN <br /> (Cnxk ons Rem enryl ❑ 2. STAINLESS STEEL WA, STEEL CUD WIFIBERGIASS ❑ 9. FRP NON-0ORROOIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) to COATED STEEL <br /> ❑ 5. CONCRETE <br /> DATE INS�'ALLEo <br /> TANK INTERIOR LINING L RUBBER LINED ❑ J. EPDXY LINING ❑ 5. GLASS LINING 95, UNKNDWNtlJ O O <br /> ORCOATING ❑ PHENOLIC LINING �]e UNLINED [199,9.OTHER O[ <br /> 13 2. KYD LINING e. (Forloca eon ) <br /> (check one it..o ) DATE INSTALLE is <br /> OTHER CORROSION _MANUFACTURED CATHODIC ❑ ]. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN AN o <br /> PROTECTION IF APPLICABLE PROTECTION ❑ e. IMPRESSED CURRENT 099. OTHER (Forbca ..NY) <br /> (Check ons item a wry) ❑ 2.BACIURCIALANODE OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> SPILL AND OVERFILL /G ✓� YEAR INSTALLED TYPE(Fwbcal..ornI) Ohm <br /> (Check alf that aPPM �1. SPILL/CONTAINMENT [& ALARM S FILL TUBE SHUT OFF VALVE <br /> CJ 2, DROP TUBE ❑ 2. BALLFLOAT 0 l E%EMPT <br /> [3]. STRIKER PLATE <br /> IV.TANK LEAK OE CTION <br /> P IF DOUBLE WALL TANK OR TANK WITHBUDDER Check arra 4em on ): <br /> IF SINGLE WALL TAN Ineck e9 that age 1r <br /> ❑ <br /> ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> I. VISUAL PORTION ONLY) 5. MANUAL TANK GAUGING(MTG) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSEZONE m 2 CONTINUOUSINTERSTITIAL MONITORING <br /> ❑ ]. CANTINUOUSATG <br /> ❑ T. GROUNDWATER ❑ ]. MANUALMONITORING <br /> ❑ a. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ a. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED GATE UST USED(YR/MOIDAY) <br /> ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT kUTERIALi <br /> 91 ❑Y ❑N <br /> FOIT611y SWRCB Form <br /> CUPAFORM(4199) <br />